Towards a person-centred cognitive behaviour therapy

Counselling Psychology Quarterly, December 2005; 18(4): 329–336

Towards a person-centred cognitive behaviour therapy* NINA JOSEFOWITZ1 & DAVID MYRAN2 1

Department of Adult Education, Community Development and Counselling Psychology, Ontario Institute for Studies in Education/University of Toronto, Canada and 2University of Toronto and Centre for Addictions and Mental Health, Canada

Abstract Person-centred therapy was developed by Carl Rogers [ Journal of Consulting Psychology 21, 97–103 (1957); On becoming a person, Boston: Houghton Mifflin (1961)] and focuses on the importance of the therapeutic relationship for effective therapy. Rogers identified three necessary and sufficient conditions that are related to a positive outcome in therapy. These are: acceptance of the client, accurate empathy and congruence on the therapist’s part. The present paper considers the definitions of the three core conditions and examines ways in which interventions, developed by cognitive behaviour therapy (CBT), can be informed by these conditions, as identified by Rogers and his followers. We argue that CBT, while using different interventions than those traditionally used by person-centred therapists, can be practiced as a highly empathic, person-centred form of therapy.

Keywords: Carl Rogers, client-centred therapy, cognitive behaviour therapy

Introduction Numerous studies have demonstrated that a positive therapeutic alliance is related to outcome across all modalities of psychotherapy (Bordin, 1979; Goldfried & Davison, 1976, 1994; Horvath, 1994; Horvath & Symonds, 1991), including cognitive behaviour therapy (Constantino, Arnow, Blasey, & Agras, 2005; Klein et al., 2003; Krupnick et al., 1996; Marmar, Horowitz, Weiss, & Marziali, 1986; Raue, Goldfried, & Barkham, 1997). One of the exceptions is Safran’s work on alliance rupture (Safran, Muran, Samstag, & Stevens, 2001), In addition, factors that are traditionally part of a positive therapeutic alliance, such as empathy, acceptance, land warmth, are rarely mentioned. Cognitive behaviour therapy (CBT) was initially developed to treat depression and has been shown to be effective for a wide range of difficulties (for example, Leahy, 2004). Treatment manuals, clinical research, as well as clinical texts on cognitive behaviour therapy, refer to the importance of a collaborative relationship (Beck, 1995; Persons, Davidson

*A version of this paper was presented at the Third Multicultural Counselling Conference, OISE/UT, Toronto, June 2005. Correspondence: Nina Josefowitz, Department of Adult Education, Community Development and Counselling Psychology, Ontario Institute for Studies in Education/University of Toronto, 252 Bloor Street West, Toronto, Ontario, M5S 1V6, Canada. E-mail: [email protected] ISSN 0951-5070 print/ISSN 1469-3674 online ß 2005 Taylor & Francis DOI: 10.1080/09515070500473600

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& Tompkins, 2000). However in contrast to the specificity in describing CBT intervention there is little exploration within the CBT literature on factors that contribute to a collaborative relationship. CBT is a structured form of therapy that moves through phases and where the therapist has a relatively high activity level, in that the therapist may direct and focus treatment. One of the difficulties is that some of the core CBT techniques, if improperly utilized, can lead to clients feeling judged rather than part of a collaborative process. At its worst, CBT can feel like a debate between the therapist and client, where the clients’ affect is ignored in favour of their thoughts. The challenge is to combine an empathic stance and positive therapeutic alliance with the active focused treatment components of CBT.1 Person-centred therapy, developed by Carl Rogers (Rogers, 1957, 1961), offers a specific framework for developing the therapeutic alliance. Rogers focused on the therapeutic relationship and identified three ‘necessary and sufficient’ conditions for effective therapy, including acceptance or unconditional positive regard for the client, empathy, and therapeutic genuineness. Since Rogers’ initial work, person-centred therapy has developed into a highly complex, broad therapeutic orientation. Current person-centred therapists can, however, be broadly divided into two orientations. The first are experientialist and are primarily comprised of therapists and researchers who are interested in work related to focusing (Gendlin, 1996) and/or process experiential therapy (Greenberg, Rice, & Elliott, 1993). The experientialists, while maintaining Rogers’ focus on the centrality of the therapeutic relationship, also include the therapist actively guiding the therapeutic process. The second broad orientation is the non-directive client-centred group (NDCC) (e.g. Bozarth, 2002; Brodley, 2002; Raskin, 2002). The NDCC group’s main focus is on the importance of a non-directive empathic therapeutic stance. The therapist follows the client and checks with the client regarding their understanding, but is not active in directing the therapeutic process. There are major differences between CBT and person-centred therapy, including the extent to which therapy is symptom-focused, the extent of structure and activity on the therapist’s part, the primacy of cognitions in understanding behaviour and affect, and the belief in the client’s inherent ability to self-actualize and move towards health. However, it is not the goal of this paper to explore the differences in the two therapeutic orientations. Lietaer (2002), in discussing experiential therapy, divides the role of the therapist into a relational and a task-oriented component. It is helpful to use this distinction in understanding therapy, generally. This distinction permits us to accept that different therapeutic orientations can differ dramatically in the task-oriented components, while having similar relational components. Indeed, research has consistently found that a positive therapeutic relationship is predictive of effective therapy, irrespective of the therapeutic orientation. Bozarth (2002), in a review of the research literature, found that the relationship variables, which are most frequently related to therapeutic effectiveness, were the core conditions identified by Rogers, i.e. empathy, genuineness and unconditional positive regard. The research literature suggests that, in examining how to enhance the therapeutic relationship in the context of CBT, it would be useful to examine Rogers’ core conditions. CBT encompasses a wide variety of therapeutic interventions. This paper will focus on examining how to structure a session and conduct a thought record, which are essential components of CBT, while considering the factors identified by Rogers as essential to a positive therapeutic relationship. We will first, briefly, give an overview of Rogers’s three core conditions.

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Overview of Carl Rogers’ necessary and sufficient conditions Rogers identified three necessary and sufficient conditions for effective therapy. The first condition is ‘‘acceptance’’, which is often referred to as respect for the patient and, sometimes, as ‘‘unconditional positive regard’’. Martin (1989) defines this concept as: ‘‘respect is reflected in the dependable acceptance the therapist gives the client – a non-judgmental openness to let the client think, feel, and say whatever he is experiencing, without losing the sense that the therapist accepts him as a person with worth’’ (page 12). Rogers’ second condition, empathy, has received a great deal of attention in the psychological literature, though there is a lack of agreement regarding a definition (Bohart & Greenberg, 1997). At the core of empathy, however, is the therapist’s ability to understand the client’s world and to communicate this understanding to the client by his or her verbal and non-verbal expression (Barrett-Lennard, 1981; Bohart & Greenberg, 1997). Empathetic communication involves accurate reflection of the client’s content and affect (Carkhuff & Berenson, 1977; Truax & Carkhuff, 1967), as well as the ability to hear a client’s intended meaning or the therapist’s ‘felt sense’ of the client’s communication (Bradley, 2002; Elliott, Watson, Goldman, & Greenberg, 2004). The third condition, which is the therapist’s genuineness or congruence, refers to the therapist relating to the client in a manner that is real and present (Martin, 1989). Goal setting and structuring a session CBT therapy starts with exploring a client’s goals for therapy. Setting goals is a process of collaboration, where the therapist listens to the client and encourages the client to articulate concrete specific goals that can be achieved. Ideally, the therapist is able to help the client articulate his goals with greater concreteness and specificity, which is congruent with the patient’s goals/aspirations. The therapist uses the clinical skills of empathic reflection, in addition to focused questions, that encourage the client to become more specific. CBT therapists characterize the form of questions used as ‘Socratic questioning’ or ‘guided discovery’ to indicate that it is through the use of questions, which encourage self-exploration, that therapeutic information is elicited. As clients become more specific and concrete, they also disclose more personal material and the therapist’s non-judgemental stance becomes of critical importance. The therapeutic relationship will be strengthened to the extent that the client feels understood and that therapy will address important goals. CBT sessions start with client and therapist collaboratively setting an agenda. Agenda is a term that originated in the business world and many novice therapists fear that agendasetting will be experienced as unempathic and business-like. However, setting the agenda can be a process of empathic collaboration between the therapist and client. The therapist needs to explain that the purpose of agenda is to maximize the possibility that therapy will focus on the important issues. The process of setting an agenda includes asking the client to actively consider what he wants to focus on and to articulate his priorities. The client has to trust that his goals and objectives will be valued by the therapist, and that he can risk disclosing issues where he may be ashamed or embarrassed. Frequently, clients only place highly sensitive issues on the agenda after they have developed a positive working alliance with their therapist. Setting an agenda is also a process where the therapist can actively direct the client to consider placing certain items on the agenda that the therapist considers to

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be of importance. For example, if an issue was discussed in the previous session, the therapist might suggest adding it to the agenda. When items are suggested by the therapist, it is important that the therapist fully explains his rationale so that it is clear that the suggestion originates from the therapist genuinely caring that the therapy-hour focuses on issues that are important to the client. Setting goals and agendas for the therapy-hour has a meta-message that is highly consistent with the values of person-centred psychotherapy. These include that (1) the issues that are important to the client will be focused on in therapy, (2) the therapist wants to listen to and understand the client’s central issues, (3) the client will be active in setting the direction of therapy and (4) the therapist will behave in a genuine manner, by letting the client know if they have concerns that they think the client should consider addressing.

Working with a thought record Working with a thought record involves three processes: accessing automatic thoughts, examining thoughts and developing new beliefs.

Accessing automatic thoughts Eliciting automatic thoughts involves assisting the client in focusing on specific situations where they have experienced emotional distress, and encouraging the client to identify as accurately as possible the thoughts he was experiencing at the time. Often, eliciting a client’s thoughts is a process that involves carefully listening to a client’s description of his experience and sorting out, with the client, the feelings, thoughts and meanings that he brought to this particular situation. CBT therapists use a combination of Socratic questioning and reflecting back the client’s cognitions or automatic thoughts. Clinicians and researchers who have built on Rogers’ work have emphasized the importance of empathy, and the therapists’ accurate reflection of clients’ content and feelings (Carkhuff & Berenson, 1977; Martin, 1989). Accurate reflection of clients’ experience is also of central importance in CBT; however, CBT therapists reflect clients’ automatic thoughts and the meanings that clients bring to a situation, as well as directing clients’ attention to the relationship between the client’s thoughts and their emotional experience. Hearing the therapist reflect back his thoughts often enables a client to further explore the meaning of a situation and articulate his thought process. Just as clients are frequently not fully aware of their emotional experience, clients are frequently not fully aware of their automatic thoughts or of the meaning of a given situation. In the context of an empathic relationship, the process of eliciting automatic thoughts encourages self-exploration and self-understanding. If a client feels judged, he is unlikely to share his thoughts, or even to acknowledge shameful or embarrassing thoughts to himself. Two of Rogers’s necessary conditions for effective therapy are acceptance of the client and genuineness. In CBT, the therapist’s attitude is one of genuine curiosity about the client’s experience and how the client understands a specific situation. Curiosity is not traditionally articulated as an important therapeutic attitude in person-centred therapy, yet it seems highly consistent with the conditions of acceptance and congruence. It can be tempting, when a client experiences difficulty accessing certain thoughts or meanings, for the therapist to articulate what the therapist believes the client is thinking. The therapist needs to hold back and give the client the opportunity to explore for themselves the meaning


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of a specific situation. If the client continues to experience difficulty, the therapist may suggest possible meanings. It is important that this be done in a tentative manner where the therapist checks with the client. CBT is often mistakenly described as a cold, intellectual form of therapy. What is ignored in this description is that the identification of thoughts and, in particular, core beliefs, can be an emotionally intense experience. Research from a number of sources indicates that for clients to access their cognitians in a specific situation it may be necessary for them to re-experience the affect associated with that situation (Greenberg & Safran, 1986; Teasdale & Fogarty, 1979; Teasdale, Taylor, Cooper, Hayhurst, & Paykel, 1995). Disclosing thoughts and the meaning of a situation are highly personal and require an ability to trust in the therapist’s capacity to understand and accept the client. As in other types of therapy, the therapist has to provide an environment where the client feels safe to experience and explore intense affect. Examining thoughts In CBT, once the therapist and client have identified the client’s thoughts, the next task is to identify a thought that is most central to the client’s distress and examine the evidence that supports or disconfirms the thought (Beck, 1995; Persons et al., 2002). If done without regard for the therapeutic relationship, the therapist can be experienced as judgemental, discounting of the client’s reality or pushing the client to think differently. The purpose in examining automatic thoughts is to assist the client in understanding the basis of his thought, as well as to attend to new information. During this process, the client is encouraged to attend to information from his past, his current environment or in his own internal experience, which he has not previously attended to. Incorporating this new information changes the meaning of a situation. The CBT therapist uses specific techniques to assist the client in attending to information that was previously filtered, minimized or ignored. This process is not one where the therapist ‘tells’ the client what to think, or ‘tells’ the client that his thinking is irrational or dysfunctional. Instead, the process is a structured exploration of the client’s thoughts and the meaning he brings to a situation. The therapist’s attitude needs to be one of respect for the client, coupled with genuineness in his curiosity and openness to understanding the client’s cognitions and feelings, as well as emotional empathy for the difficulty of the situation that the client is describing. For example, a client might believe that she is responsible for having been sexually assaulted. Therapy might involve a non-judgemental exploration of the client’s behaviours and thoughts in the situation that led up to the assault; the therapist understanding how the client blames herself, reflecting it back to the client, and encouraging further exploration. For example, the therapist might make an intervention such as: ‘‘If I understand correctly, because you got into a car with a man you could previously trust, that you are responsible for him assaulting you?’’ Examining thoughts can also involve creating evidence logs, where the therapist and client explore the evidence that supports the thought, as well as evidence against it. When therapists ask clients to examine the evidence for their thoughts, they are encouraging them to suspend some of the certainty they attach to their thoughts. Therapists need to convey an understanding that important life experiences have helped shape the client’s filters or habitual way of seeing the world. Therapists also need to convey a desire to help the client be less constrained by these experiences, and this is why they are trying to assist the client to look at ‘‘data’’ previously ignored.

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One technique used in examining the evidence for a thought is to assist clients in labeling their thought processes with a variety of labels, such as ‘‘catastrophic thinking’’, ‘‘mind reading’’, ‘‘personalization’’, etc. (Beck, 1995). When reading about this process, it can easily lead to the assumption that the therapist labels and judges the client’s cognitions. However, providing a label usually occurs after a collaborative exploration of the client’s thought processes. The label encapsulates or provides a shorthand way of referring to the type of cognitive process that the client uses and which resonates with the client’s own experience. For example, after exploring the situation, a graduate student realized that he had jumped to conclusions about his professor’s negative evaluation of him. Together the client and therapist formulated that this is an example of ‘‘mind reading’’. The process of providing a label can be experienced as the therapist’s empathic understanding of the client’s thought processes, rather than as the therapist judging the client’s thoughts as irrational or dysfunctional. Creating alternative or balanced thoughts The next step in the process of CBT therapy is to develop either a balanced thought, which incorporates all of the evidence or new thoughts reflecting issues that the client previously had not attended to (Beck, 1995; Persons et al., 2002). This stage of therapy often occurs spontaneously as the client attends to information that he previously ignored. If it occurs spontaneously, the therapist’s intervention is to empathically reflect back to the client the alternative thought that the client articulated, to encourage the client to reflect on this alternative thought and incorporate it into his cognitive process. In some cases, however, the process of creating balanced or new thoughts does not occur automatically. In this situation, the therapist’s job is to focus the client’s attention on all of the evidence that was collaboratively elicited and to ask the client to consider how to include all of the evidence. The therapist remains respectful of the way in which the client is able to attend to new information and create balanced or new thoughts. This process is often misconstrued as one where the therapist ‘tells’ the client what to think. The client needs to develop his own alternative or balanced thoughts. The role of the therapist is to reflect back to the client all of the evidence that has been examined in relation to the thought, and inviting the client to consider how to attend to all of the material. If relevant, the therapist might validate the client’s difficulty in attending to, or believing in, new information that discounts previously held beliefs. Conclusion Until recently, CBT generally focused on evaluating and teaching specific interventions with little mention of the contribution of the therapeutic alliance. The term collaborative relationship is unique to CBT and focuses on working with a client as an equal, rather than forming a positive emotional bond or positive therapeutic alliance. However, research clearly indicates that, in CBT therapy, like other forms of therapy, a positive therapeutic alliance is an essential component to effective therapy (Goldfried & Davison, 1994; Raue et al., 1997). The present paper explores how, within the structure of CBT, therapists can empathically attend to clients’ experience and provide a safe non-judgemental environment where clients can identify and explore their thoughts, affect and behaviours. Despite the universality of the importance of the therapeutic relationship, CBT is clearly a different form of therapy than person-centred therapy. This paper suggests that some of Rogers’ original concepts


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can be operationalized in ways that permit for more structure and specific attention to the role of cognition and thoughts in forming clients’ experiences. Notes 1

For ease of reading clients will be referred to as ‘he’ throughout the article.

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