Continuing Education Activity

Person-centered therapy, also referred to as non-directive, client-centered, or Rogerian therapy, was pioneered by Carl Rogers in the early 1940s. This form of psychotherapy is grounded in the idea that people are inherently motivated toward achieving positive psychological functioning. The client is believed to be the expert in their life and leads the general direction of therapy, while the therapist takes a non-directive role. This activity reviews person-centered therapy and highlights the role of the interprofessional team in improving care for patients who undergo person-centered therapy.

Objectives:

• Identify the core conditions of person-centered therapy.
• Explain the therapeutic process of person-centered therapy.
• Describe the benefits and criticisms of person-centered therapy.
• Review the efficacy of person-centered therapy in the treatment of common psychiatric illnesses.

Introduction

Person-centered therapy, also referred to as non-directive, client-centered, or Rogerian therapy, was pioneered by Carl Rogers in the early 1940s. This form of psychotherapy is grounded in the idea that people are inherently motivated toward achieving positive psychological functioning. The client is believed to be the expert in their life and leads the general direction of therapy, while the therapist takes a non-directive rather than a mechanistic approach.

The therapist's role is to provide a space conducive to uncensored self-exploration. As the client explores their feelings, they will gain a clearer perception of themselves, leading to psychological growth. The therapist attempts to increase the client's self-understanding by reflecting and carefully clarifying questions. Although few therapists today adhere solely to person-centered therapy, its concepts and techniques have been incorporated eclectically into many different types of therapists' practices.[1]

Issues of Concern

Origins of Person-Centered Therapy

Person-centered therapy, also referred to as non-directive, client-centered, or Rogerian therapy, was pioneered by Carl Rogers in the early 1940s. His ideas were considered radical; they diverged from the dominant behavioral and psychoanalytic theories at the time. Rogers' method emphasizes reflective listening, empathy, and acceptance in therapy rather than the interpretation of behaviors or unconscious drives.[1] In the 1960s, person-centered therapy became closely tied to the Human Potential Movement, which believed that all individuals have a natural drive toward self-actualization. In this state, one can manifest their full potential. According to Rogers, negative self-perceptions can prevent one from realizing self-actualization.

Process

Rogers postulated that a state of incongruence might exist within the client, meaning there is a discrepancy between the client's self-image and the reality of their experience. This incongruence leads to feelings of vulnerability and anxiety.[2] Person-centered therapy operates on the humanistic belief that the client is inherently driven toward and has the capacity for growth and self-actualization; it relies on this force for therapeutic change.[3] The role of the counselor is to provide a nonjudgmental environment conducive to honest self-exploration. The therapist attempts to increase the client's self-understanding by reflecting and carefully clarifying questions without offering advice. The therapist functions under the assumption that the client knows themselves best; thus, viable solutions can only come from them.

Direction from the therapist may reinforce the notion that solutions to one's struggles lie externally. Through client self-exploration and reinforcement of the client's worth, person-centered therapy aims to improve self-esteem, increase trust in one's decision-making, and increase one's ability to cope with the consequences of their decisions.[4] Rogers did not believe that a psychological diagnosis was necessary for psychotherapy.[2]

The Necessary and Sufficient Conditions

Rogers identified 6 conditions that were necessary and sufficient to facilitate therapeutic change:

1. Therapist-client psychological contact: The therapist and client are in psychological contact
2. Client incongruence: The client is experiencing a state of incongruence
3. Therapist congruence: The therapist is congruent, or genuine, in the relationship
4. Therapist unconditional positive regard: The therapist has unconditional positive regard toward the client
5. Therapist empathic understanding: The therapist experiences and communicates an empathic understanding of the client's internal perspective
6. Client perception: The client perceives the therapist's unconditional positive regard and empathic understanding [2]

Core Conditions

Rogers defined three attitudes on the therapist's part that are key to the success of person-centered therapy. These core conditions consist of accurate empathy, congruence, and unconditional positive regard.[2][3]

Accurate Empathy

The therapist engages in active listening, paying careful attention to the client's feelings and thoughts. The therapist conveys an accurate understanding of the patient's private world throughout the therapy session as if it were their own. One helpful technique to express accurate empathy is reflection, which involves paraphrasing and/or summarizing the feeling behind what the client says rather than the content. This also allows clients to process their feelings after hearing them restated by someone else.

Congruence

The therapist transparently conveys their feelings and thoughts to genuinely relate to the client. Within the client-therapist relationship, the therapist is genuinely himself. The therapist does not hide behind a professional façade or deceive the client. Therapists may share their emotional reactions with their clients but should not share their personal problems with clients or shift the focus to themselves in any way.

Unconditional Positive Regard

The therapist creates a warm environment that conveys to clients that they are accepted unconditionally. The therapist does not signal judgment, approval, or disapproval, no matter how unconventional the client's views may be. This may allow the client to drop their natural defenses, allowing them to freely express their feelings and direct their self-exploration as they see fit.

Criticisms

Critics have contended that the principles of person-centered therapy are too vague. Some argue that person-centered therapy is ineffective for clients who have difficulty talking about themselves or have a mental illness that alters their perceptions of reality. There is a lack of controlled research on the efficacy of person-centered therapy, and no objective data suggests its efficacy was due to its distinctive features.[1] People have asserted that the unique qualities of client-centered therapy are not effective, and the effective aspects are not unique but characteristic of all good therapy.[5]

Clinical Significance

Indications for Psychotherapy

Clinicians may initiate or refer a patient to psychotherapy for reasons not limited to the following:

• Treatment of a psychiatric disorder
• Help with maladaptive thoughts or behaviors
• Support during stressful circumstances or when a chronic problem impairs functioning
• Improve a patient's ability to make positive behavioral changes, such as healthy lifestyle changes or increasing adherence to medical treatment
• Helping with interpersonal problems

Person-centered therapy can be used in various settings, including individual, group, and family therapy, or as part of play therapy with young children. There are no set guidelines on the length or frequency of person-centered therapy, but it may be used for short-term or long-term treatment. Person-centered therapy may be a good choice for patients who are not suitable for other forms of therapy, such as cognitive-behavioral therapy (CBT) or psychoanalysis, which require homework assignments and the ability to tolerate high levels of distress that may occur when elucidating unconscious processes.[6]

Person-centered therapy relies on the client's active participation and may not be appropriate for individuals who lack motivation or insight into their emotions and behaviors.

Efficacy

To examine the efficacy of person-centered therapy in the treatment of various psychiatric conditions, this article will include recent studies using any form of non-directive counseling based on Rogerian principles, including person-centered therapy/client-centered therapy (PCT/CCT), non-directive supportive therapy (NDST), and supportive counseling/therapy (SC/ST). Important limitations exist as NDST is not a popular focus of most researchers in the field. It is often only included as a control for nonspecific therapeutic conditions, and therapists may not have administered optimal treatments. Consequently, the researcher's allegiance to a specific therapy could skew results.[7][8] Additionally, given the inherent vagueness of this type of therapy, there could be differences in how NDST/SC/ST was defined and implemented.

Depression

There is evidence in the literature to support the efficacy of non-directive therapy as a treatment for depression. Three meta-analyses conducted within the past decade concluded that ST/NDST is an effective therapy for adult depression but may be less effective than other forms of therapy.[7]  Importantly, the authors mention that researcher bias may have played a role in the superiority of the other psychotherapies. After controlling for researcher allegiance, the differences in efficacy between non-directive therapy and other psychotherapies disappeared. This was true for all three meta-analyses. One study also notes no significant difference in effect sizes of non-directive supportive therapy versus full person-centered therapy. However, this was only based on 2 studies.[7]

A 2021 randomized, non-inferiority trial comparing person-centered therapy with CBT as a therapeutic intervention for depression found that person-centered therapy was not inferior to CBT at 6 months; however, person-centered therapy may be inferior to CBT at 12 months. The authors suggest that there needs to be continued investment in person-centered therapy to improve short-term outcomes.[9] In adults with depression older than the age of 50, one meta-analysis found non-directive counseling to be effective, with effects maintained for at least 6 months. However, non-directive counseling was less effective than CBT and problem-solving therapy.[10] 

A 48-week randomized control trial compared nonspecific supportive psychotherapy with cognitive behavioral analysis system of psychotherapy (CBASP) in patients with chronic depression who were unmedicated (n=268). Both groups demonstrated a reduction in depressive symptoms. Patients who received nonspecific supportive psychotherapy had a lower response rate than patients who received CBASP.[11] However, there were fewer severe adverse events with nonspecific supportive psychotherapy.[12]  Follow-up two years posttreatment found the benefits of the two treatments were comparable on multiple measures, including the number of asymptomatic weeks.[13] 

Bipolar disorder

One randomized controlled trial (n= 76) compared ST/SC to CBT in treating bipolar disorders and observed no difference in relapse rates.[14] 

Anxiety

Non-directive psychotherapy may be comparable to CBT and other forms of psychotherapy in treating generalized anxiety disorder in older adults.[15]

Post-Traumatic Stress Disorder 

In the treatment of post-traumatic stress disorder (PTSD), non-directive therapy may be an effective treatment.[16] Person-centered therapy may be comparable to evidence-based treatments for PTSD, with fewer dropouts.[17] Trauma treatment research consistently shows lower dropout rates with person-centered therapy compared to other types of treatment. PCT may be a reasonable option in settings without the resources to provide the high levels of training required in other therapeutic modalities for PTSD. Despite mixed evidence of its efficacy compared to other forms of psychotherapy, person-centered therapy is consistently recommended as a viable option, given the rising demand for psychological therapy.[9] The literature suggests an important role for PCT in low-resource communities where the training and supervision of more technical psychotherapies may be less readily available, and access to mental healthcare is limited.[17][18]

Enhancing Healthcare Team Outcomes

It is estimated that 1 in 5 adults living in the United Kingdom and the United States have a mental illness.[19] Most patients receive treatment for a nonpsychotic psychiatric disorder in a primary care setting. In recent years, mental health care in children and adolescents has increased more rapidly compared with adult mental health care. Again, most of this mental health care has been provided by non-psychiatrist providers.[20] In response to this rising need, there have been recent efforts to integrate behavioral health and primary care—an interprofessional care strategy will result in the best outcomes. The Collaborative Care Model employs a team-based approach emphasizing collaboration between different providers and has demonstrated improvement in depression outcomes compared to the usual care that persists for at least 24 months.[21] 

Compared to other forms of psychotherapy, person-centered therapy has the advantage of being more readily available and more easily implemented in other healthcare roles.[11] Rogers himself stated that professional psychological knowledge is not required of the therapist; the qualities of the therapist and their experiential training are more important than intellectual training.[2] In a small randomized controlled trial comparing various psychotherapeutic interventions of PTSD in a low-resource setting, all participants experienced symptom reduction regardless of the intervention. Importantly, nurses felt that supportive counseling was the most transferable to their respective work environments.[18]  Another pragmatic trial (n= 228) found that non-directive counseling provided by public health nurses is an efficacious treatment for post-partum depression.[22] Non-directive supportive counseling has a broader application beyond behavioral health. Healthcare providers can employ these principles to help patients make informed decisions about their physical health; however, more research is necessary to assess the impact of this approach on healthcare outcomes.[23] 

Review Questions

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Disclosure: Lucy Yao declares no relevant financial relationships with ineligible companies.

Disclosure: Rian Kabir declares no relevant financial relationships with ineligible companies.