The Research and Evidence Base Supporting Client-Centred Therapy
Client-centred and person-centred therapies are one of the most well-known forms of counselling available today. But what is the scientific evidence to support their use? In this blog I outline research in client-centred therapy from its early period to present time.
At its inception in the 1942, the validity of the client-centred approach has been maintained through empirical research. It wasn't until 1951 however when the milestone text, Client-Centred Therapy: Its Current Theory, Research, and Practice, was published revealing a wealth of research evidence to support client-centred therapy. Of particular interest to me is the stress on effective practice as the foundation for developing the client-centred approach, as opposed to basing psychotherapy on solely on theoretical concepts:
"Thus, in the field of therapy the first requisite is a skill which produces an effective result. Through observation of the process and the result a parsimonious theory may be developed which is projected into new experiences in order to be tested as to its adequacy. The theory is revised and modified with the purpose — never fully attained — of providing a complete conceptual framework which can adequately contain all the observed phenomena. It is the phenomena which are basic, not the theory" (Rogers, 1951, pp. 15-16).
Carl Rogers, founder of the client-centred approach, and his team of psychotherapy researchers at the Counseling Centre in the University of Chicago got busy on studying the 'basic phenomena', and were ready to communicate the findings. Among a team of over twenty researchers formed the largest research group for psychotherapy the world had known at the time (Wilkins, 2016), where various elements of client-centred therapy were investigated. Rogers contributions to research during his years at Chicago, he would earn him the American Psychological Association's Distinguished Scientific Contribution Award - a testament to the progress made in scientific discovery in psychotherapy (Sommerbeck, 2002).
A notable method used to effectively evaluate the outcomes of client-centred therapy and the impact on the self was the Q-Sort Method developed from the 1930s by English psychologist and researcher William Stephenson, and still continues to be used today. This worked by having clients sort a number of statements about their pre-therapy perception of themselves, their ideal self, and post-therapy perception of themselves. By analysing the differences in correlations between the statements, it could be revealed that clients move more towards the benchmark of their ideal self through the process of psychotherapy. It's also worth adding here that Rogers was the first counsellor to publish transcribed recordings of counselling a client, meaning accurate representations of the therapy could be studied and analysed.
Nathanial Raskin, a notable client-centred practitioner, colleague and friend of Rogers, completed a PhD thesis dedicated to looking at the locus of evaluation and it's adjustment through client-centred therapy. This is concerned with how much someone feels in contact and trusting of their experience, and whether they base their attitudes on their own feelings compared to depending on the attitudes and beliefs of others. The findings of Raskin's (1952) research is that through therapy, the locus of evaluation shifted from external to internal, indicating that in client-centred therapy, clients reconnect with their authentic experiencing and can shift their values and beliefs accordingly.
Snyder's (1943) research included the analysis of non-directive techniques, which supported the application of client-centred therapy as a distinct and unique approach to psychotherapy. This was an important development for the client-centred approach, as Roger's therapy was strongly influenced by the work of Otto Rank and Jessie Taft, which meant that distinguishing client-centred therapy allowed for greater accuracy in research.
One final example from this period is how the concept of 'self' in client-centred therapy was beginning to be employed in a theory of personality. Studies by Raimy (1948) aimed to use that concept as a focal point for measurement, and in his research revealed how the self-construct has an organisational nature which is modified through the course of therapy. The findings shown that as therapy progressed, clients experienced more openness and acceptance of themselves and their experience.
The Beginning of the Client-Centred Approach
The 'Integrative Statement' of Personality Change
The research findings that emerged from the Chicago resulted in Rogers developing a hypotheses for personality change in psychotherapy, which has had a far reaching impact on the world of psychology, sociology, and health care (Wilkins, 2010). Roger's 1957 paper posited the six necessary and sufficient conditions of personality change. In this proposition, Rogers hypothesised that there are fundamental requirements for personality adjustment to take place from a helping relationship:
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 endeavours 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.
It's important to note, that while this hypothesis emerged from the findings in client-centred therapy research, Rogers' claim is that these are universal conditions that must be present in any relationship for psychological change to be successful. A big claim, and does it stand up to scrutiny? The most recent summary of the evidence that supports the therapeutic conditions can be discovered in Norcross (2011), who has compiled and reviewed multiple studies on the therapeutic conditions.
In a commentary on the therapeutic conditions, Silberschatz (2007) outlines the main limitations and criticisms of this hypothesis as lacking not in their necessity, but their sufficiency. It is argued that some clients may benefit from more technical approaches that are endorsed in client-centred therapy, and furthermore that patient factors are a more significant barrier to benefitting from therapy that have not been taken into consideration, i.e. motivation and readiness, emotion regulation, and severity of presenting problems (I have enjoyed discovering this commentary, and I think it will be informative to update this blog at a later time with some counterpoints). Nevertheless, it is acknowledged that despite these limitations, Roger's integrative statement has had a profound impact on the psychotherapy profession, highlighting key criteria for evaluating psychotherapy in research:
"Despite these limitations, Rogers’ article is a classic in our field and appropriately so. Although it was written over 50 years ago, many of the ideas are pertinent to current, intensively debated issues such as the role of techniques in therapy, the therapeutic relationship, therapeutic alliance, and empirical research in psychotherapy [...] I believe that Rogers’ contributions place him among the most important figures in the history of psychotherapy" (Silberschatz, 2007 p.267).
Rogers left Chicago in 1957 to accept a position of professor at the University of Wisconsin. Rogers move and completion of the 'Wisconsin Project', the large scale research project aimed at implementing client-centred therapy with psychiatric in-patients with schizophrenia, marked an important development from client-centred therapy to the person-centred approach, where principles of therapeutic growth were explored more deeply in group therapy (Rogers 1961; Sommerbeck, 2002). However, while the term 'person-centred' encompasses the approach to communication and relationships in different contexts and implementations, client-centred therapy is considered as the classical form of person-centred therapy which share the same underlying philosophy and values about the nature of the person and psychological growth (Bozarth, 1999).
The most recent publication that presents current research in person-centred therapy is Person-Centered and Experiential Psychotherapies Work: a review of the research on counseling, psychotherapy and related practices. In actual fact, if you want to get straight to the point, we need only take a look at the findings indicated in this book to see the positive results from the evidence. Elliot and Freire (2010) start by reviewing the findings from six different meta analyses, from 1980, 1994, 1996, 2001, 2004, and 2008, which include randomized controlled trials, the 'gold standard' in quantitative research methodology. To put this into perspective, the total amount of individual studies reviewed throughout these meta-analyses clocks in at 482. The most recent meta-analysis by Elliot and Freire has confirmed and bolstered the findings of meta-analyses over the past 40-plus years, which show that clients access person-centred and experiential therapies (PCEs) to elicit significant and lasting changes in themselves which are comparable to changes seen in other therapies like CBT, but are otherwise inaccessible had they not attended therapy. An interesting finding from this study shows that when lumped together with 'supportive therapies', PCEs were shown to be trivially inferior to CBT across 76 comparative studies between PCEs and CBT. However, on inspection, it turns out that 'supportive therapies' were discovered to be poorly practised, diluted forms of person-centred therapy. When supportive therapies as a factor were removed, person-centred and experiential therapies were equal or marginally more effective than CBT. It's not all the same after all!
In the same publication, Timulak and Creaner (2010) outline some of the findings from a qualitative meta-analysis of nine selected studies with inclusion criteria for PCEs, aiming to try to uncover some of the more subtle details behind what clients experience through psychotherapy and how individuals have benefitted from therapy in their own words and expression. Eleven meta-categories or themes were selected from the data set; smoother and healthier emotional experiencing, appreciating vulnerability, experience of self-compassion, experience of resilience, feeling empowered, mastering symptoms, enjoying change in circumstances, feeling supported, enjoying interpersonal encounters, self-insight/self-awareness, and changed view of others.
Finally, the most up to date look of the evidence is provided in a review by Elliot (2016). A detail worth mentioning here as it relates to client-centred therapy, is that in nine studies that compared process-experiential therapy to non-directive therapy, the process-experiential were considered trivially better but inconsistent. This finding makes sense, as it denotes the risk-adverse approach of the non-directive approach endorsed in client-centred therapy, which can be compared to some of the reasons for client drop out in Timulak and Creaner's (2010) qualitative meta-analysis, which showed that conflict emerged between emotion focused therapists and their clients.
Contemporary Research in Person-Centred Therapy
And the facts are indeed friendly for client-centred therapy and PCEs. We can safely say based on our most up to date research that it is much more likely that receiving client-centred counselling will leave someone better off compared to if they did not have therapy at all. In this blog, I have shown that client-centred therapy emerged within a culture of science and research, and since the 1940s has been practiced and reported up to present time. In addition, the gaps in knowledge and future directions are established, and work is already underway so that we are bound to learn more about the effectiveness and the efficiency of client-centred and PCEs.
For further interest, check out the The Person-Centred Journal and Person-Centred and Experiential Psychotherapies journals as a place to start for relevant articles.
Summary: The Facts are Friendly
Bohart, A, C., Tallman, K., (2010) 'Clients as Active Self-Healers: Implications for the person-centered approach'. In Cooper, M., Watson, J, C., Hölldampf, D. (eds.) Person-Centered and Experiential Psychotherapies Work: a review of the research on counseling, psychotherapy and related practices. Monmouth: PCCS Books Ltd.
Bozarth, J. (ed.) (1999) Person-Centered Therapy: A Revolutionary Paradigm. Herefordshire: PCCS Books.
Cooper, M (2019) Is Person-Centred therapy Effective? The Facts. Available at: https://mick-cooper.squarespace.com/new-blog/2019/7/2/is-person-centred-therapy-effective-the-facts
Elliott, R. (2016) 'Research on person-centred/experiential psychotherapy and counselling: summary of the main findings'. In: Lago, C., Charura, D (eds.) The Person-Centred Counselling and Psychotherapy Handbook: Origins, Development, and Current Applications. England: Open University Press.
Elliott, R., Freire, E. (2010) 'The Effectiveness of Person-Centered and Experiential Therapies: A review of the meta-analyses'. In: Cooper, M., Watson, J, C., Hölldampfd, D. (eds.) Person-Centered and Experiential Therapies Work: a review of the research on counseling, psychotherapy and related practices. Monmouth: PCCS Books Ltd.
Norcross, J. (ed.) (2011) Psychotherapy Relationships that Work (2nd edn.). New York: Oxford University Press.
Raimy, Victor C. (1943) The self-concept as a factor in counseling and personality organization. Ph.D. thesis, Ohio State University.
Raimy, Victor C. (1948) 'Self reference in counseling interviews', Consulting Psychology Journal, 12, pp. 153-163.
Raskin, N, J. (1952) 'An Objective Study of the Locus-of-Evaluation Factor in Psychotherapy'. In Wolff, W., Precker, J, A. (eds.) Success in Psychotherapy. New York: Grune and Stratton.
Raskin, N, J. (1974) 'Studies of Psychotherapeutic Orientation: Ideology and Practice'. In: American Academy of Psychotherapists, Research Monograph No,1, pp. 5-33.
Rogers, C, R. (1942) Counselling and Psychotherapy: Newer Concepts in Practice. Boston: Houghton Mifflin Company.
Rogers, C, R. (1951) Client-Centered Therapy: Its Current Theory, Research, and Practice. Boston: Houghton Mifflin Company.
Rogers, C, R. (1961) On Becoming a Person: A Psychotherapist's View of Psychotherapy. Boston: Houghton Mifflin Company.
Snyder, W. U. (1943) An investigation of the nature of non-directive psychotherapy. Ph.D. thesis, Ohio State University.
Snyder, W. U. (1947) 'The present status of psychotherapeutic counselling', Psychology Bulletin, 44, pp. 404-424
Timulak, L., Creaner, M. (2010) 'Qualitative Meta-Analysis of Outcomes of Person-Centered and Experiential Psychotherapies'. In: Cooper, M., Watson, J, C., Hölldampfd, D. (eds.) Person-Centered and Experiential Therapies Work: a review of the research on counseling, psychotherapy and related practices. Monmouth: PCCS Books Ltd.
Wilkins, P. (2016) Person-Centred Therapy: 100 Key Points and Techniques. London: Routledge.
