Many people seek therapy every day for a wide variety of different reasons. Some of these are suffering from clinically diagnosed disorders such as schizophrenia, depression or anxiety. Others may simply be experiencing more minor difficulties in their life that are causing them to feel unhappy and are therefore seeking some kind of independent guidance. For individuals seeking help this can be a daunting process – there are so many types of therapists available from counsellors to life coaches to psychologists to psychiatrists. Each of these appears to be offering something slightly different to the client. In addition, each individual seeking to become a client will bring his or her own personality to the client – therapist relationship. Similarly each therapist brings his or her own approach and personality to this relationship. There are many broad approaches to therapy within psychology and psychotherapy. The following piece focuses on three popular approaches to therapy popularised and used mainly by psychologists. It will discuss aspects of the client-therapist relationship within each of these three approaches. The approaches considered are Humanistic/phenomenological, Psychodynamic / psychoanalytical and Cognitive / Behavioural therapy. In the following paragraphs each type of therapy will be described, where appropriate the key names in the field will be introduced and the aims of the approach will be examined. Throughout this piece aspects of the relationship between the therapist and the client and the impact this has on the process of therapy will be discussed. Lastly a summary of the approaches will be provided and thoughts on the client therapist relationship will be introduced. The final section will also consider how this relationship can be managed to ensure success for the client.
The first approach to be described will be the humanistic approach – this is also referred to in some of the literature in the area as the phenomenological approach. This approach focuses on the self and the way in which a person views themselves. One of the most recognised names in humanistic therapy is Carl Rogers, a psychologist who was working in the 1950’s. Rogers believed that each of us have a self-concept which is made up of two different components. He believed that this self-concept consisted of a real self – who is how we truly believe ourselves to be and an ideal self – the way a person would like to be (Eysenck, 1995). These two concepts of the self can be assessed using something-called Q sort methodology. When completing a Q-sort individuals are required to sort through cards that have a variety of statements on and rank these cards in an order according to which are most like them and which are least like them. The statements relating to the self-concept would include things such as “I am a happy person”, “I enjoy being with other people”, “I am a friendly person”, “I am a positive person” and so on. The individual is then asked to carry out the same process with the cards for which statements are most like their ideal self. The therapist will then use a method of analysis to calculate the difference between the person’s view of their actual self and their ideal self. This measurement is referred to as the amount of incongruence between the two selves. In the humanistic/phenomenological viewpoint it is this incongruence that is believed to contribute to mental illness. Therefore the less incongruence that exists between the two selves the less likely a person is to encounter mental health problems. Carl Rogers developed the Person-Centred approach (also known as client-centred) to therapy in the 1950’s. This approach aims to reduce the amount of incongruence between the individuals’ perceptions of their actual and ideal self. Rogers identified three conditions which he described as “necessary and sufficient” to his approach to therapy (Wickman & Campbell, 2003). These conditions are
3. unconditional positive regard
Rogers felt that these three factors needed to be provided to the client from the therapist to ensure that the process would be successful. The key factor in humanistic approaches to therapy is the emphasis on the therapist displaying warmth and empathy to the client regardless of the clients’ behaviour. The therapist must offer the client empathy and understanding; this must come across as genuine for the client to reap the most benefit from this approach. In the ideal parent-child relationship to a great extent exhibits this unconditional regard – the child develops in an environment where they feel that no matter what their parents will support them and accept them. However as we all know this isn’t always the case. The idea behind person-centred therapy is that at some stage in our lives we experience conditional regard – in other words people only displaying warmth and empathy towards us if we are behaving in a manner they deem to be acceptable. Rogers believed that on occasions this interferes with the natural “organismic process for growth” (Lopez, 1987). For example as we are growing and developing it is not unusual to start to take on other people values because we feel this is what is required of us to received acceptance. For example a child may want to keep their bedroom tidy because they know that this will please their mother (Eysenck, 1995). This internalisation of others values is known as introjection. Sometimes when this happens to us it can lead to confusion and a sense of not knowing what our true values/selves really are – this leads then to a greater incongruence between the two selves. A person may believe that to gain the acceptance of others they have to behave in a particular way, although naturally they would prefer to act differently. Rogers believed that if therapy includes unconditional positive regard from the therapist it would reactivate the client’s potential for natural growth and development of their own true values. Unconditional positive regard means that the therapist will be non-judgemental and will offer acceptance and empathy to the client regardless of their behaviour. Therefore the client will be able to behave as their true selves and be accepted – hopefully this behaviour will then be transferred outside of the client-therapist relationship.
One of the most well known approaches to therapy is the Psychodynamic or psychoanalytic approach. This is probably the type of therapy that most non-psychologists or people with limited knowledge of therapy would think of. This approach was largely developed and popularised by Sigmund Freud in the early twentieth century. This approach is in many ways quite different to the humanistic therapy described above. Freud believed that the relationship between client and therapist should remain neutral in order for therapy to be successful, rather than the warmth and empathy based relationship used in humanistic therapy. In addition in psychoanalysis a lot of emphasis is placed on the unconscious – the thoughts and memories that are part of us but that are not easily accessible. Freud believed that as we are developing as children we might experience things we find painful or unacceptable. As a result these memories/experiences are repressed to the back of our minds and eventually into our unconscious, where they may still have an effect on us even though we are not immediately aware of their existence. This process of repression to the unconscious reduces the anxiety associated with recognising and facing up to these memories and experiences. Freud’s theory of child development suggests that we progress through a series of phases. Firstly there is the oral stage where children gain pleasure from their mouths, as we know young children will often automatically put things in their mouths. Secondly we progress to the anal stage, which normally happens during toilet training, and then, finally we progress to the phallic stage where pleasure is derived from the genitals. A child can develop conflicts at any point during this development process leading to them spending more time in a particular phase (Appignanesi & Zarate, 1999). During adulthood if difficulties are encountered the adult may regress to one of the stages, often to the stage where they experienced conflicts previously in their lives. To overcome such difficulties Freud and other psychoanalyst’s believed/believe that individuals need to gain access to their repressed memories from their unconscious. By facing up to and recognising these repressed ideas the individual can then continue to develop and grow in “normal” manner. As well as remembering the repressed thoughts during therapy Freud encouraged individuals to experience and express the feelings associated with them as well (Eysenck, 1995). He also encouraged something he called “transference” during therapy. This is a process where the client transfers the feelings and emotions associated with the repressed ideas onto the therapist. Often these feelings and emotions have also been repressed as the individual has felt that they were unable to express them previously. The idea behind transference is that the therapist reacts in a neutral way to these feelings so that the client is able to continue expressing these emotions without experiencing any retaliation from the therapist. In a similar way to humanistic therapy this process then provides the client with a form of acceptance. Psychoanalytical therapy can take many forms however there are three that are the most common approaches. Hypnosis is often used to encourage the client access and express the memories from their unconscious. These ideas can be difficult to access and when a client is hypnotised they are often more willing and open to expressing and articulating these repressed memories. There have been several problems associated with this technique, firstly not everyone is susceptible to hypnosis – some resist it and are therefore impossible to hypnotise. In addition when a client is hypnotised it can be difficult to assess the accuracy of the memories being expressed – therefore after hypnosis further probing from the therapist may be required. Freud also used dream analysis, as he believed that our dreams reflect a lot of what is contained in our unconscious. The therapist then has to interpret the dreams to access the repressed memories. Again there are some difficulties with this approach because it relies greatly on the interpretations skills of the therapist. Lastly free association is commonly used where the client is encouraged by the therapist to say the first thing that comes into their head. This to can prove difficult as often clients will not want to express their repressed thoughts. Therefore when the client begins to express resistance the therapist will begin to gently probe the client to try and gather more from them. The psychoanalytical / Psychodynamic approach can generally be defined in three consecutive steps (Bienvenu, Piper, Debbane, & De Carufel, 1986):
2. The therapist will try to interpret this stage by encouraging the client to access repressed memories.
3. The client develops a new experience.
A lot has been written about the psychodynamic/psychoanalytical approach to therapy and there has been a lot of scepticism about Freud’s theories. One of the main criticisms is that there is a lack of evidence to support the approach – despite this the approach is still widely used by therapists today and many clients emerge satisfied with the therapy received.
A more recent approach to therapy with individuals is cognitive behavioural therapy or CBT. This approach was introduced at the end of the twentieth century and has been described as the most evidence-based form of psychotherapy (Chase-Gray & Grant, 2005). The most common type of CBT involves some type of exposure to something a client has been avoiding and is most often used in the treatment of phobias and anxiety based symptoms. This therapy is based on the idea that fear is a learned response and once a fear exists avoidance of the fear stimulus develops to maintain the fear/anxiety (Rowa & Antony, 2005). The aim therefore of the therapist using CBT is to change both the thought processes and the behaviour of the client. To do this the therapist will work with the client to develop an exposure hierarchy. Here the client lists a number of situations involving the fear stimulus ranging from very to mildly frightening/anxiety provoking. For example if a client had a fear of spiders a mildly frightening situation may be seeing a spider on the television. A very frightening situation may be holding a spider in their hands. The client and therapist work together and the client will gradually experience each of the situations listed on the exposure hierarchy until the phobia has gone. The fear is extinguished and the avoidance behaviour has been replaced. This approach to therapy combines a cognitive approach in the development of the exposure hierarchy where thought processes are examined with the behavioural element in the client actually working through and experiencing each of the situations. This is often combined with learning techniques of relaxation – the client is taught how to get him or herself into a relaxed state and they are encouraged to get into this frame of mind before encountering each of the situations listed in the hierarchy. This approach is also known as systematic desensitisation.
CBT as the name suggests draws on ideas from both cognitive and behavioural approaches to therapy. The behaviourist approach relates to theorists such as Pavlov (classical conditioning) and Watson (operant conditioning). The aim is to produce associations between a stimulus and a response. These types of associations often lead to the development of a mental illness in the first place so the behaviourist approach to therapy looks at replacing the learned, normally negative association with something else. In classical conditioning it is simply stimulus – response that is considered – for example Pavlov’s classic experiment where dogs began to associate the sound of a bell with food and therefore eventually the sound of the bell alone led to the dogs salivating. In operant conditioning a reward or punishment is also used. In terms of therapy positive reinforcement is used to encourage positive behaviours. In contrast selective punishment is used to reduce and eventually extinguish negative behaviours exhibited by the client (Eysenck, 1995).
In summary it can be seen that the humanistic approach to therapy encourages a warm and empathy based relationship between the therapist and client. This relationship is then expected to encourage the client to feel accepted, as the therapist is non-judgemental and accepting of them regardless of their behaviour. The ultimate aim of this approach to therapy is to reduce the amount of incongruence between the client’s actual self and their ideal self by showing them that it is OK to be yourself and that you can find acceptance being like that. In contrast the therapist using a psychoanalytical / psychodynamic approach to therapy remains neutral towards the client. By taking this approach it is expected that the client is able to freely express their feelings and emotions without experiencing any kind of retaliation from the therapist. Similarly to the humanistic approach it provides for the client a “safe” environment where they will not be judged. The ultimate aim of therapy from this approach is to access the clients repressed emotions, memories and thoughts and for the client to be able to accept and admit to these to enable them to continue with their development and growth. The process of the therapy encourages the client to ascertain the truth about themselves and to “delight in their individuality” (Roth, 1996). The CBT approach is less focused on the actual relationship between the client and the therapist and instead concentrates more on the process of therapy and making changes to the client’s thoughts and behaviour. The ultimate aim of this approach is for the client to become independent and able to overcome the thoughts/beliefs that are limiting them and to change their behaviour from avoidance to actually facing situations. Relaxation is used to help the client to do this. Similarly the behaviourist approach to therapy again uses techniques that produce a change in the client’s behaviour. This can be done through learning a stimulus response association or by using rewards and/or punishment to produce new associations.
From the brief descriptions above the three approaches to therapy appear very distinct. Many practising psychologists will actually specialise in just one of these approaches, which emphasises the distinction. Kahn (1996), made a suggestion that it might actually be the relationship between the client and the therapist that is the most important factor determining the therapies success, and therefore, the relationship is the in fact the therapy. He also talks about bringing the different approaches together and how it might be that combining aspects of them could bring about a successful outcome. As stated at the beginning of this piece each client is and individual and is therefore unique. As such different approaches to therapy are needed and will suit different clients. Some clients have the unfortunate experience of trying a number of different types of therapy before they find one that is suitable for them. It is the job of the experienced practitioner to make a judgement as to the best approach to take with each new client they encounter.