Humanistic Psychotherapies

Humanistic
Psychotherapies
Handbook of Research and Practice
Second Edition
Edited by
David J. Cain
Kevin Keenan
Shawn Rubin
American Psychological Association • Washington, DC

Humanistic
Psychotherapies
Second Edition
Copyright © 2016 by the American Psychological Association. All rights reserved. Except
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Library of Congress Cataloging-in-Publication Data
Humanistic psychotherapies : handbook of research and practice / David J. Cain,

Kevin Keenan, and Shawn Rubin. — Second edition.
pages cm
Includes bibliographical references and index.
ISBN 978-1-4338-2077-9 — ISBN 1-4338-2077-3 1. Humanistic psychotherapy. I. Cain,
David J. II. Keenan, Kevin, (Psychology professor) III. Rubin, Shawn.
RC480.5.H83 2016
616.89'14—dc23
2015013996
British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.
Printed in the United States of America

Second Edition
http://dx.doi.org/10.1037/14775-000
To Bobbi, my soulmate, love of my life, best friend,
and center of my universe.
—David J. Cain
To all those who have taught us about being human and humanistic:
our mentors, therapists, colleagues, clients, and students.
—Kevin Keenan
To my loving parents Cheryl and Fred and to my brothers
and their beloved wives and children: Harley, Shannon,
Alexandra, and Norah; and Jonathan, Stephanie,
Logan, and Grant.
—Shawn Rubin
CONTENTS
Contributors.................................................................................................. xi
Preface......................................................................................................... xiii
Acknowledgments..................................................................................... xvii
Introduction ................................................................................................. 3
David J. Cain, Kevin Keenan, and Shawn Rubin
I. Historical and Conceptual Foundations............................................... 9

Chapter 1. Psychological Foundations for Humanistic
Psychotherapeutic Practice............................................. 11
Mick Cooper and Stephen Joseph
II. Overviews of Research....................................................................... 47

Chapter 2. Effective Humanistic Psychotherapy
Processes and Their Outcomes........................................ 49
Michael J. Lambert, Louise G. Fidalgo,
and Madeline R. Greaves
vii
Chapter 3. Qualitative Research and Humanistic
Psychotherapy................................................................. 81
Heidi M. Levitt
Chapter 4. The Role of Empathy in Psychotherapy:
Theory, Research, and Practice..................................... 115
Jeanne C. Watson
Chapter 5. Emotion in Psychotherapy:
An Experiential–Humanistic Perspective..................... 147
Antonio Pascual-Leone, Sandra Paivio,
and Shawn Harrington
III. Major Therapeutic Approaches..................................................... 183

Chapter 6. Person-Centered Therapy:
Past, Present, and Future Orientations......................... 185
David Murphy and Stephen Joseph
Chapter 7. Contemporary Gestalt Therapy.................................... 219
Philip Brownell
Chapter 8. Focusing-Oriented–Experiential Psychotherapy:
From Research to Practice............................................ 251
Kevin C. Krycka and Akira Ikemi
Chapter 9. Existential Psychotherapies........................................... 283
Meghan Craig, Joël Vos, Mick Cooper,
and Edgar A. Correia
Chapter 10. Emotion-Focused Therapy............................................ 319
Rhonda N. Goldman
IV. Therapeutic Modalities................................................................... 351

Chapter 11. Empirically Supported Humanistic Approaches
to Working With Couples and Families........................ 353
Catalina Woldarsky Meneses and Robert F. Scuka
Chapter 12. Humanistic Psychotherapy With Children.................. 387
Dee C. Ray and Kimberly M. Jayne
viii contents

V. Therapeutic Issues and Applications.............................................. 419
Chapter 13. The Good Therapist: Evidence Regarding
the Therapist’s Contribution to Psychotherapy............ 421
Kevin Keenan and Shawn Rubin
Chapter 14. Client Variables and Psychotherapy Outcomes............ 455
David M. Gonzalez
VI. Analysis and Synthesis................................................................... 483

Chapter 15. Toward a Research-Based Integration of Optimal
Practices of Humanistic Psychotherapies...................... 485
David J. Cain
Index......................................................................................................... 537
About the Editors..................................................................................... 555
contents ix
CONTRIBUTORS
Philip Brownell, MDiv, PsyD, Gestalt Center for Psychotherapy and Train-
ing, New York, NY
David J. Cain, PhD, ABPP, CGP, Fellow in Clinical Psychology of the
American Board of Professional Psychology, Carlsbad, CA
Mick Cooper, PhD, Department of Psychology, University of Roehampton,
London, England
Edgar A. Correia, PgD, MA, Doctoral Candidate, Department of Counsel-
ling, University of Strathclyde, Glasgow, Scotland
Meghan Craig, PgD, PsychD, CPsychol, Independent Practitioner and
Consultant, YSC Business Psychology, London, England
Louise G. Fidalgo, BS, Clinical Psychology Training Program, Brigham
Young University, Provo, UT
Rhonda N. Goldman, PhD, Illinois School of Professional Psychology at
Argosy University, Schaumburg
David M. Gonzalez, PhD, Counseling Psychology Program, University of
Northern Colorado, Greeley
Madeline R. Greaves, BS, Applied Psychology Program, Eastern Washing-
ton University, Cheney
xi
Shawn Harrington, MA, Clinical Psychology Training Program, University
of Windsor, Windsor, Ontario, Canada
Akira Ikemi, PhD, Graduate School of Professional Clinical Psychology,
Kansai University, Osaka, Japan
Kimberly M. Jayne, PhD, LMHC, NCC, RPT, Department of Counselor
Education, Portland State University, Portland, OR
Stephen Joseph, PhD, School of Education, University of Nottingham,
Jubilee Campus, Nottingham, England
Kevin Keenan, PhD, Michigan School of Professional Psychology, Farming-
ton Hills
Kevin C. Krycka, PsyD, Psychology Department, Seattle University,
Seattle, WA
Michael J. Lambert, PhD, Department of Psychology, Brigham Young
University, Provo, UT
Heidi M. Levitt, PhD, Clinical Psychology Program, Department of Psychol-
ogy, University of Massachusetts Boston
Catalina Woldarsky Meneses, PhD, Private Practice, Geneva, Switzerland
David Murphy, PhD, School of Education, University of Nottingham,
Jubilee Campus, Nottingham, England
Sandra Paivio, PhD, Department of Psychology, University of Windsor,
Windsor, Ontario, Canada
Antonio Pascual-Leone, PhD, Psychological Services and Research Center,
Department of Psychology, University of Windsor, Windsor, Ontario,
Canada
Dee C. Ray, PhD, LPC-S, NCC, RPT-S, Department of Counseling and
Higher Education, University of North Texas, Denton
Shawn Rubin, PsyD, Chair, School of Clinical Psychology, Saybrook
University, San Francisco, CA
Robert F. Scuka, PhD, MSW, National Institute of Relationship Enhance-
ment, Bethesda, MD
Joël Vos, PhD, Department of Psychology, University of Roehampton,
London, England
Jeanne C. Watson, PhD, Department of Applied Psychology and Human
Development, Ontario Institute for Studies in Education, University of
Toronto, Toronto, Ontario, Canada
xii contributors

PREFACE
Every book has a story. This one’s started in 1997 when I began to pon-
der the possibility of assembling the research literature on the major variables
and theories of humanistic psychotherapies. At the time, humanistic psycho-
therapies were thought by many clinicians and academics to have little or no
empirical support for their effectiveness, except for research supporting client-
or person-centered therapy. This assumption was erroneous but common in
mainstream psychology and psychotherapy. By the early 1990s, humanistic
therapists and scientists had generated substantial research evidence support-
ing its effectiveness. However, much of this research remained unknown to
university faculty, clinical practitioners, or the general public. Even by the
late 1990s, although there were chapter reviews on research in humanistic
psychotherapies, there was no text available to provide comprehensive evi-
dence that humanistic psychotherapies were indeed effective for a wide range
of clients and problems. Moreover, the extant reviews of humanistic psycho-
therapies did not illustrate how research might be applied to practice, some-
thing that the first and second editions of Humanistic Psychotherapies provide.
To remedy this deficit, I invited Jules Seeman to coedit Humanistic
Psychotherapies: Handbook of Research and Practice. Jules Seeman was one of
our best and brightest and had for many decades served as a role model of an
xiii
exemplary person-centered–humanistic psychologist, teacher, researcher,
and therapist. In 2002, the first edition of Humanistic Psychotherapies
was published. Fortunately, Humanistic Psychotherapies received positive
reviews and was well received by practicing therapists, graduate students,
and psychotherapy researchers. Consequently, a second edition was pro-
posed to the American Psychological Association, and the final product
is in your hands.
Thirteen years have passed since the publication of the first edition
of Humanistic Psychotherapies, which remains the primary text in the field
devoted to demonstrating how research may be transformed into effective
practice. When the first edition was published, there was a need to demon-
strate that humanistic approaches were effective for a wide variety of client
populations. This was important, as mentioned previously, because main-
stream psychotherapy remained uninformed or skeptical that humanistic
psychotherapies were supported by sound research. This goal was achieved,
because the research evidence showed that all major humanistic therapies
were indeed effective. In fact, as the chapters in this volume attest, the
evidence now indicates that humanistic psychotherapies are equivalent or
superior to all major therapeutic systems, including cognitive–behavioral
therapy, which remains the most frequently practiced form of therapy in
the United States.
Despite the progress in conducting psychotherapy research, the
authors of Humanistic Psychotherapies strongly advocate that researcher–
practitioners carry out further studies. This is especially important because
students trained as researcher–practitioners are most likely to conduct
needed research that will enable us to continually improve and refine prac-
tice. The reality is that, despite the enormous impact of humanistic psycho-
therapy on the larger field, humanistic psychotherapists remain a relatively
small group, partly because students in graduate programs in clinical coun-
seling psychology and clinical social work are often not adequately exposed
to humanistic models. Clearly, more graduate faculty still need to join the
ranks of these programs to provide students with the opportunity to learn
humanistic approaches well enough to implement them with competence.
A parallel need is for students to have more humanistically oriented super-
visors available to them. Postgraduate training programs are also needed so
that professionals who want to practice humanistic psychotherapies have
resources for in-depth learning.
We are happy to report that the authors of this volume are, indeed,
the kind of researcher–practitioners needed to carry out the studies that will
help advance the theory and practice of humanistic psychotherapy. Although
many of them are long-time veterans in the field, a good portion of them are
what I refer to as the fourth generation—that is, those who are in their 30s
xiv preface

and 40s. Many in this group have already established themselves as talented
therapists, researchers, and writers. Our future is in good hands.
Although the future of humanistic therapies looks bright, it is essential
that we continue to be pioneers in exploring the farther reaches of the thera-
peutic endeavor. As Carl Rogers might remind us, whatever we discover, “the
facts are friendly” and will enable us to move forward, continually guided by
compelling evidence.
preface xv
ACKNOWLEDGMENTS
I, David J. Cain, acknowledge the many people who have inspired me

in my professional development and endeavors. Carl Rogers’s impact on my
thinking and therapeutic practice has been profound. He is my constant
reminder to be fully present, listen with sensitivity, and seek to understand
while providing a safe, supportive, and caring relationship for my clients.
Art Combs instilled faith and optimism in me that clients are inclined to
move toward healthy behavior. Clark Moustakas taught me to engage my
spontaneous and creative self to tap my clients’ resources and to value my
own emergence as a person and therapist. Tom Gordon was a close friend and
tennis partner who taught me the value of democratic principles in working
with children and families to resolve conflicts and foster growth
Jules Seeman, who was the coeditor of the first edition of Humanistic
Psychotherapies, was one of our shining stars and a superb synthesizer of com-
plex ideas. He was an exemplary psychologist, teacher, researcher, and thera-
pist until his passing at age 95. Jules had an extraordinary ability to articulate
with incredible clarity his clients’ experiences. Gene Gendlin enabled me to
take a leap forward by articulating the importance of attending to the client’s
bodily felt sense of a problem and helping clients to clarify the meaning of
their experience and find the wisdom of the body’s way of knowing.
xvii
Art Bohart pointed to the central role of the client in making therapy
work effectively and helped us understand how important it is to encour-
age clients’ active participation in therapy. He also served in the role of
my “thinking partner” when I was pondering various therapeutic issues. Les
Greenberg and Robert Elliott and their associates have enabled me to value
the central role that emotion plays in the lives of our clients. Irv Yalom and
other existentialists raised my consciousness about the challenges of the exis-
tential givens of life with which we must all grapple.
In addition to those named above, enormous appreciation and rec-
ognition is due to the three generations of humanistic psychologists, psy-
chotherapists, and researchers who laid the ground on which contemporary
humanistic psychotherapies now stand.
My coeditors, Kevin Keenan and Shawn Rubin, made substantive and
distinctive contributions to the creation of this text.
I want to thank the American Psychological Association for publishing
a second edition of Humanistic Psychotherapies. Susan Reynolds was of great
assistance throughout. Her wise counsel proved to be valuable in dealing with
some of the inevitable challenges in such a project.
Special recognition is due to my parents, Esther and Russell Cain, for
teaching and modeling for me how to do a good job at whatever I undertook
in life.
I, Kevin Keenan, acknowledge Billie Ables, whose kind critique of my

work taught me how to listen more deeply to words both on the page and in
the air. Thanks go also to my father, H. B., for instilling in me his ancestrally
rooted love of language. Many thanks go to my students and my clients, who
continually teach me the gifts of understanding: wanting to understand and
wanting to be understood. Deep appreciation goes to the women in my life;
my mother, Marion; my wife, Carol; and my daughter, Mera. Their support
has enabled my work and given it meaning. A final note of appreciation goes
to my colleagues, David J. Cain and Shawn Rubin, for inviting me to con-
tribute to the making of this book.
I, Shawn Rubin, acknowledge the incredible efforts of the coeditors and

authors of this book. I am deeply indebted to my many mentors in human-
istic psychology, including Clark Moustakas, Diane Blau, Marjie Scott, Erik
Craig, Matt Dickson, Kirk Schneider, Ed Mendelowitz, Mark Stern, Tom
Greening, Ray Gage, Cathie Kurek-Ovshinsky, Donna Rockwell, Kerry
Moustakas, David Dietrich, and Don Spivak. I dedicate this book to the
founders of humanistic psychology, to its current leaders and innovators, and
to the future generations of the movement.
xviii acknowledgments

Humanistic
Psychotherapies
Second Edition
INTRODUCTION
David J. Cain, Kevin Keenan, and Shawn Rubin
There are a lot of good reasons to read this book. If you are a gradu-
ate student learning therapy, a professor teaching therapy, a psychotherapy
researcher, or a therapist who wants to incorporate humanistic concepts, rela-
tional emphases, and response styles into your current approach, this book has
much to offer. Your teachers, the authors of the chapters, are among the most
accomplished humanistic therapists and researchers in the field. The primary
goal of the book, to translate psychotherapy research into practice, is accom-
plished with ample therapist–client dialogue that demonstrates how the core
humanistic variables (e.g., empathy) and major schools (e.g., person-centered,
Gestalt) can be optimally implemented in a seamless manner. No matter
what your experience level as a therapist, this book has a range and depth
of learning that will enhance your skills and benefit your clients whether
Proper steps were taken in all case studies reported in the second edition of Humanistic Psychotherapies to
protect the confidentiality of clients.
http://dx.doi.org/10.1037/14775-001
Humanistic Psychotherapies: Handbook of Research and Practice, Second Edition, D. J. Cain, K. Keenan, and
S. Rubin (Editors)
Copyright © 2016 by the American Psychological Association. All rights reserved.
3
in individual, couples, child, or family therapy. Humanistic Psychotherapies:
Handbook of Research and Practice, Second Edition is unique in its review of the
humanistic psychotherapy research literature from its inception. It illustrates
clearly how to become a more evidence-based therapist while retaining one’s
core humanistic principles and values.
DEFINING HUMANISTIC PSYCHOTHERAPIES
The reader may fairly ask, “What defines therapy as humanistic?” The
term humanistic, as used here, is understood to incorporate approaches vari-
ously defined as experiential, existential, relational, and phenomenological.
Therapies that come under the humanistic umbrella share a number of core
variables and emphases. They include
77 an optimistic view of clients as resourceful and naturally inclined
to grow and develop their potential.
77 a belief that the quality of the relationship between therapist
and client provides a safe sanctuary that supports the thera-
peutic process and that is growth inducing in and of itself. The
primary endeavor of humanistic therapists, therefore, is the cre-
ation of an optimal therapeutic relationship that is individual-
ized to adapt to clients’ needs as they evolve throughout the
course of therapy.
77 the core role of therapist empathy in grasping the personal mean-
ing of the client’s experience, facilitating self-exploration and
setting in motion a self-reflective process that promotes intraper-
sonal and interpersonal learning that leads to fresh perspectives
and more effective ways of living.
77 a phenomenological emphasis that focuses on clients’ subjective
world with the understanding that their current perception is
reality and can best be understood by putting aside hypotheses,
diagnoses, and preconceptions in an attempt to take in their
experience as freshly as possible.
77 a strong emphasis on the critical role emotion plays in both psy-
chopathology and psychological health with an understanding
of the adaptive role emotion plays in effective decision making,
emotion regulation, and effective functioning.
77 a focus on the self and self-concept of the client with the under-
standing that the way clients experience the self has a great
influence on their behavior. Enhancing self-exploration, self-
definition, reconstrual of the self, and the development of
4 cain, keenan, and rubin

self-knowledge and self-efficacy are primary endeavors of the
humanistic therapist.
77 a view that meaning is not a given but is constructed from
the raw data of experience, including one’s culture, values, per-
spectives, and personal history. Humanistic therapists strive to
enable their clients to grasp the larger meanings and purposes
of their lives.
77 a view that people are essentially free to choose the manner
and course of their lives and their attitude toward events and
that freedom, choice, and responsibility are interwoven and
inescapable.
77 an understanding that all people must confront existential givens
and the challenges they present, including (a) life versus death;
(b) freedom, choice, and responsibility; (c) isolation versus con-
nection; (d) meaning versus meaninglessness; (e) their “thrown-
ness” (forces or events beyond one’s control); (f) capacity for
awareness; (g) anxiety as an inevitable aspect of the human
condition; and (h) the fact that they are essentially embodied.
77 a holistic view of people as unique, indivisible organisms com-
posed of interrelated systems that cannot be reduced to the sum
of their parts. People are conceived as inseparable from their
environment and are therefore best understood as beings-in-
the-world.
RESEARCH SUPPORT FOR HUMANISTIC PSYCHOTHERAPIES
In the past few decades, the research on humanistic psychotherapies has

continued to accumulate. The effectiveness of all major branches of humanis-
tic psychotherapy continues to be validated by new research carried out since
the first edition of Humanistic Psychotherapies was published. The research
supporting person-centered therapies and child therapy remains strong, and
the evidence for focusing-oriented therapy, Gestalt therapy, and existential
therapies is growing at a more modest pace. The good news is that Gestalt
and existential scholar–practitioners have begun to embrace and produce
considerably more research than in previous decades.
More recently, the integrative movement in psychotherapy has gained
momentum and influence. As noted above, many of the core concepts and
styles of practice common to humanistic psychotherapies have increasingly
been incorporated into mainstream psychotherapies. This is especially so in
terms of other therapeutic approaches incorporating an emotion focus in their
work, with an understanding that core beliefs are fundamentally embedded
introduction 5
in emotion schemes. Furthermore, we are now beginning to understand that
therapeutic learning is likely to be more integrated and lasting when it is
experienced emotionally.
Other areas in which humanistic psychotherapies have made an impact
include an emphasis on therapist presence, relational depth, a focus on the
self and self-concept of the client, and more reliance on the client’s resourceful-
ness for change. The positive psychology movement is clearly grounded in
humanistic premises and values. Almost every major school of psychotherapy
now understands and embraces the critical importance of Rogers’ core thera-
pist conditions of empathy, acceptance, and genuineness in facilitating client
growth. Emphases on phenomenology and working in the subjective world of
the client have also been embraced in mainstream psychotherapy.
Humanistic psychotherapists have also increasingly integrated concepts
and methods from many therapeutic approaches. While remaining true to
their core values and beliefs, humanistic therapies have incorporated aspects
of other therapies in a manner that retains the integrity of the model used.
This means that clients are viewed as capable partners with whom the thera-
pist collaborates to make therapeutic adjustments and to create an optimal
relationship and style of therapy that best fits their needs. This approach is
guided by research of the past few decades that has clearly shown that client
involvement is the best predictor of a good outcome.
Although it is likely that individual schools of psychotherapy will be
maintained and taught in their pure forms, it is clear that most therapists
will increasingly use concepts and methods from other sources to supple-
ment their work and to meet the needs of clients who are not responding
optimally to the core model. Emotion-focused therapy, while essentially
grounded in person-centered therapy, has integrated aspects of experien-
tial, Gestalt, and existential therapies. Therefore, it may be considered one
of the first humanistic–integrative therapies. Similarly, integrated models
of person-centered and existential–humanistic and Gestalt therapies have
become more prominent in the past decade.
Developments in the field of humanistic psychotherapy have demon-
strated that it has a renewed impact on the practice of psychotherapy that
is far reaching. Kirk Schneider and Alfried Längle (2012) edited a special
section of the journal Psychotherapy that made the case that
the renewal of humanism is a viable and growing phenomenon among
the leading areas of psychotherapy and that . . . humanism is (1) a foun-
dational element of therapeutic effectiveness; (2) a pivotal (and needed)
dimension of therapeutic training and (3) a critical contributor to social
well-being. (p. 427)
Invited authors of this special section of Psychotherapy indicated that (a) human-
istic psychotherapy has become widespread in Europe, (b) multiculturalism

embraces many humanistic values, (c) humanistic values and practices have
affected the practice of psychoanalytic and other schools of psychotherapy,
(d) humanism serves as a common factor in effective psychotherapy, and
(e) humanistic models of psychotherapy have increasingly been incorpo-
rated by the general field of psychotherapy. It can be fairly argued that many
core elements of humanistic psychotherapy are vital aspects of all major
approaches to psychotherapy.
OVERVIEW OF THIS BOOK
This second edition of Humanistic Psychotherapies gives us strong reasons

for optimism. The facts are friendly. Seventy-five years of development in
theory, practice, and research have demonstrated that humanistic approaches
to psychotherapy are as effective or more effective than all other major
approaches. Substantive growth in quantitative and qualitative research on
humanistic psychotherapies has occurred over the past 25 years.
Each chapter in Humanistic Psychotherapies reviews research literature
from 2000 to mid-2014 and also provides a brief summary of the research
reviewed in the first edition. The research reviewed provides new evidence
that supports the effectiveness of all major schools of humanistic therapies
and humanistic variables for a wide range of problems.
Part I begins with a discussion of three core principles of humanistic psy-
chotherapy that are key to creating positive change: relational connection and
support, emotional expression and processing, and authenticity. Expanding
on these fundamental concepts, Part II reviews the accumulating qualitative
research that gives a glimpse into the inner world of psychotherapy as experi-
enced by therapist and client while providing a close-to-the-bone sense of how
therapy works. It also examines the continuing research support for empathy and
working with clients’ emotions as critical components of the psychotherapy pro-
cess and future outcomes. Building on this research, Part III highlights how all
major schools of humanistic psychotherapy (person-centered, Gestalt, focusing-
oriented or experiential, existential, and emotion-focused therapy) have con-
tinued to evolve into more sophisticated and research-based forms of practice.
Part IV demonstrates how various humanistic approaches for couples, families,
and children, such as filial family therapy and child-centered play therapy, have
been shown to be sufficiently effective to be considered empirically supported.
Part V reviews the client and therapist variables that promote growth and the
alleviation of psychopathology. Part VI ties everything together with a research-
based synthesis of humanistic psychotherapies, compiling the best evidence we
have into 20 proposed premises to promote the optimal practice of humanis-
tic psychotherapy that will also benefit the larger field of psychotherapy.
introduction 7
Regrettably, some areas of humanistic therapies could not be included in
the second edition, primarily because of either space limitations or an inade
quate research base. These include culture and diversity, the self and self-
concept in therapy, group and transpersonal therapy, feminist therapies, and
therapies for extreme forms of psychopathology. I hope that these areas will be
given the coverage they deserve in future reviews of humanistic psychotherapy.
In a recent article (Angus, Watson, Elliott, Schneider, & Timulak, 2014)
reviewing the humanistic psychotherapy literature over the past 25 years
(1990–2015), the results are consistent with those reported in this book.
The article makes a strong case that “qualitative and quantitative research
findings, including meta-analyses, support the identification of [human-
istic psychotherapy] approaches as evidence-based treatments for a variety
of psychological conditions” (Angus et al., 2014, p. 1). They also indicate
that many humanistic therapies meet the standard for evidence-based treat-
ments for many problems. Therefore, the findings presented in Humanistic
Psychotherapies are increasingly supported by other current reviews of the
research literature. Fortunately, the rate of new studies is increasing and
continues to provide useful evidence that guides and refines practice. Our
future looks bright, and humanistic psychotherapists have good reason to feel
confident that they are providing their clients with a high level of care that
consistently leads to good outcomes.
REFERENCES
Angus, L., Watson, J. C., Elliott, R., Schneider, K., & Timulak, L. (2014). Human-
istic psychotherapy research 1990–2015: From methodological innovation to
evidence-supported treatment outcomes and beyond. Psychotherapy Research.
Advance online publication. Retrieved from http://www.ncbi.nlm.nih.gov/
pubmed/25517088
Schneider, K. J., & Längle, A. (Eds.). (2012). Humanism in psychotherapy [special
section]. Psychotherapy, 49, 427–481.

I
Historical and
Conceptual
Foundations
1
PSYCHOLOGICAL FOUNDATIONS
FOR HUMANISTIC
PSYCHOTHERAPEUTIC PRACTICE
MICK COOPER AND STEPHEN JOSEPH
More than 60 years from its origin in humanistic psychology, human-

istic psychotherapy consists of members who continue to draw extensively
from the contemporary psychological literature (e.g., Joseph & Linley, 2006;
Watson, 2011). More widely, however, the humanistic psychotherapy com-
munity appears increasingly distanced from the leading edge of psychological
theory and research. For instance, articles in leading humanistic psycho-
therapy journals, such as Person-Centered and Experiential Psychotherapies,
rarely cite contemporary psychological evidence, and many of the key train-
ing texts make only passing reference to the contemporary psychological lit-
erature (e.g., Cooper, Schmid, O’Hara, & Bohart, 2013; Schneider, 2008).
Indeed, recently developed competencies for humanistic psychotherapeutic
practice in the United Kingdom (Roth, Hill, & Pilling, 2009) make little
direct mention of either theories or research from the field of contemporary
Thanks to Meghan Craig and Jo Pybis for comments on earlier versions of this chapter.
http://dx.doi.org/10.1037/14775-002
S. Rubin (Editors)
11
psychology, in stark contrast to psychotherapeutic orientations such as cogni-
tive–behavioral therapy, in which training texts, competencies, and journal
articles all draw extensively from—and are closely allied with—current
developments in psychology.
An example of a contemporary field of research with direct applicability
to humanistic psychology is self-determination theory (SDT), proposed by
Ryan and Deci (2000, 2002). SDT posits that human beings have three basic
psychological needs that are “essential for facilitating optimal functioning
of the natural propensities for growth and integration” (Ryan & Deci, 2000,
p. 68). The first of these is a need for relatedness—defined as feeling con-
nected to others and caring for and being cared for by those others; it sits
alongside the second need, that for autonomy (having a sense of agency and
ownership of one’s behavior), and the third, the need for competence (a sense
of mastery and accomplishment). SDT is becoming increasingly influential
in the fields of motivation and emotion, personality and social psychology,
and positive psychology; its conceptualization of need satisfaction is essen-
tially a positively phrased way of expressing what person-centered therapists
strive to achieve through the negatively phrased concepts of nondirectivity
and unconditional positive regard (Rogers, 1957). SDT provides powerful
indirect support for traditional humanistic practice (see Patterson & Joseph,
2007, for a full discussion of the compatibility between SDT and the person-
centered approach), yet it remains relatively unknown and underused in the
field of humanistic psychotherapy and counseling.
To some extent, this distancing from psychology may have emerged
because of the values of humanistic psychotherapy (see Cain, 2002; Cooper,
2007), which question the natural scientific assumptions underlying much
of psychological theory and research. Whereas psychology, for instance, aims
to establish generalized laws of human behavior, humanistic psychotherapies
emphasize the uniqueness of each person’s lived experience. Similarly, whereas
psychology tends to construe human activity in deterministic terms, humanis-
tic psychotherapies emphasize the human capacity for freedom and choice. Yet
there is also much research from a nonpositivistic, human sciences standpoint
(e.g., Giorgi, 1985; Moustakas, 2001; Wilkins, 2010), which has the potential
to inform humanistic psychotherapeutic practices. Furthermore, as Cain (2002)
pointed out, a preference for a human sciences standpoint need not necessitate
a rejection of a natural sciences one because the humanistic psychotherapies
embrace “multiple ways of knowing” (p. 9).
More important, perhaps, the humanistic psychotherapy community
may face significant risks in becoming detached from contemporary psycho-
logical theory and research. Indeed, if a psychotherapeutic approach is likened
to the body of a tree, psychological theory and evidence can be likened to
its roots in two ways: First, psychological theory can provide nourishment
12 cooper and joseph

and stimulation for the growth of a psychotherapeutic approach—fueling
new ideas and practices that can be tested, researched, and refined. In the
behavioral field, for instance, Skinner’s (1953) work on operant condition-
ing led to several advances in therapy that remain influential to this day.
Second, psychological theories and evidence can provide a grounding for
psychotherapeutic practice, ensuring that it is embedded in valid and defen-
sible models of human functioning and change. For instance, research from
the field of cognitive psychology demonstrating that people have a tendency
to overestimate risks (Kahneman, 2011) has provided powerful support and
legitimization for the cognitive therapeutic practice of challenging catastrophic
thinking (Reinecke & Freeman, 2003).
A humanistic psychotherapy that is not grounded in psychological evi-
dence and research, therefore, can be likened to a tree without roots. It is in
danger both of withering from a lack of nourishment and of being knocked
down as a result of an insufficiently robust foundation. The aim of this chap-
ter, therefore, is to contribute to a process of reconnecting humanistic psycho-
therapy to a set of psychological roots, from humanistic psychology or otherwise.
More specifically, we hope to achieve three things: First, to show that there is
a ready-made body of psychological evidence that supports core humanistic
assumptions and practices; second, to map out the kind of evidence base that
can support and nourish humanistic psychotherapeutic practice; and third, to
illustrate how the humanistic psychotherapies can draw on a range of contem-
porary psychological findings to develop their models of practice.
To these ends, we focus on three particular assumptions that are core
to humanistic psychotherapeutic practices (Cain, 2002): first, that relational
connection and support offer the optimal conditions for human well-being
and growth; second, that emotional expression and processing can contrib-
ute to positive change processes; and third, that movement toward a more
authentic state of being is psychologically beneficial. Undoubtedly, we could
have examined other core assumptions (e.g., that human beings thrive when
they have a sense of meaning and purpose in life; e.g., Park, Park, & Peterson,
2010), but space is limited. Furthermore, as indicated above, our intention is
not to carry out an exhaustive review of the psychological evidence support-
ing humanistic psychotherapeutic practices but to illustrate and exemplify
the ways in which humanistic psychotherapies can reconnect to different
psychological foundations.
RELATIONAL CONNECTION AND SUPPORT
A core assumption across the humanistic psychotherapies is that the

relational encounter between therapist and client has a “powerful growth-
inducing” potential (Cain, 2002, p. 7). Many other therapies have also
psychological foundations 13
emphasized the importance of a collaborative and nonjudgmental thera
peutic relationship (e.g., Beck, John, Shaw, & Emery, 1979). However, what
is unique among the humanistic therapies is the belief that a particular kind
of therapeutic relating has, in itself, the power to bring about positive thera-
peutic change (Rogers, 1957).
For many theorists and practitioners across the humanistic field, it is
the existence of a deep, authentic connection between therapist and client
that has the greatest potential for psychological benefit. Much of this is
derived from Buber’s (1958) concept of I–Thou and his work on dialogue
(Buber, 1947), which argued that human beings achieve their authentic
personhood only through genuine relationships with another. Rogers’s (1959,
1961) later work, with its emphasis on encounter and congruence, was partic-
ularly influenced by this argument (Anderson & Cissna, 1997); more recent
developments in the person-centered field have also been oriented around
the positive psychological potential of dialogue (Schmid, 2001a, 2001b)
or relational depth (Knox, Murphy, Wiggins, & Cooper, 2013; Mearns &
Cooper, 2005). Along similar lines, contemporary gestalt therapy has also
seen an emphasis on the deep soul nourishment that a genuine encounter
between therapist and client can provide (Hycner, 1991; Lee & Wheeler,
2013), and existential therapists such as Binswanger (1963), Laing (1965),
and Friedman (1985) have emphasized the healing power of being with
others and love.
Mearns and Cooper (2005) defined relational depth as a state in which
two people are copresent (Bugental, 1976)—that is, concomitantly open to
the impact of the other (receptivity) while also willing to share themselves in
an authentic and open way (expressivity; Cooper, 2005). Such a definition is
close to what social psychologists have defined as intimacy or intimate inter-
actions, consisting of self-revealing behaviors (cf. expressivity), a positive
regard for others, and a knowledge of their inner experiencing (cf. receptivity;
Prager & Roberts, 2004; Reis, 2001). As with conceptions of a deepened thera-
peutic encounter (Cooper, 2009), social psychologists have also argued that a
core component of intimacy is responsiveness—the extent to which partners
communicate understanding, validation, and caring in response to the other’s
self-disclosures (Laurenceau, Rivera, Schaffer, & Pietromonaco, 2004; Reis,
Clark, & Holmes, 2004).
Interpersonal Connection and Mental Well-Being and Health
To what extent, then, do theory and research from the psychological

field—and closely related areas, such as psychiatric epidemiology—support
this assertion that deep and intimate human relationships can be of benefit?

Mental Well-Being
Regarding mental well-being, one important line of evidence comes
from recent psychological work that draws on Bowlby’s attachment theory
(e.g., Bowlby, 1969, 1979), arguing that human beings have a fundamental
need for close interpersonal connection or relatedness (e.g., Baumeister &
Leary, 1995; Diener & Seligman, 2002; Ryan & Deci, 2000, 2002). In support
of this hypothesis, an abundance of psychological research has indicated that
when these basic needs are satisfied in relationships—be they at work, with
family and friends, or with caregivers during childhood—greater well-being
results (Patterson & Joseph, 2007; Sheldon, 2013).
More specific research on social support processes has shown that feel-
ing connected to others is one of the best predictors of subjectively reported
mental well-being (Aked, Marks, Cordon, & Thompson, 2008; Myers, 2004).
For instance, national surveys have indicated that people who report higher
levels of life satisfaction and happiness also report greater levels of social par-
ticipation (Aked et al., 2008); are more likely to feel that they have friends they
can count on and to trust others (Helliwell & Wang, 2010); and are more likely
to be married or cohabiting with another person than to be single, separated, or
divorced (Helliwell & Wang, 2010). Happy people also rate the quality of their
relationships as significantly higher than do those who are less happy; in addi-
tion, they spend less time alone and more time with family, friends, or roman-
tic partners (Diener & Seligman, 2002). They also tend to rate time spent
with others as more inherently rewarding than time spent alone (Hawkley &
Cacioppo, 2010), and the pursuit of interpersonal projects (such as spending
time with friends or family) is “among the most valued and enjoyed pursuits
in which people are engaged” (Salmela-Aro & Little, 2007, p. 207). Indeed,
intimacy goals have been rated as the most important in people’s lives—more
important, on average, than goals related to achievement, power, or altruism
(Salmela-Aro & Little, 2007). Although some evidence has suggested that
well-being is related to the quantity of social relationships (Wildes, Simons,
& Harkness, 2002), quality also emerges as a critical factor (Aked et al.,
2008). For instance, the association between marital status and well-being is
entirely moderated by the quality of the marriage, with only good-quality and
caring relationships bestowing mental health benefits over remaining single
(Dolan, Peasgood, & White, 2008; Goleman, 1996; Ornish, 1998; Wildes
et al., 2002).
Indeed, such is the evidence in support of the association between inter-
personal connection and well-being that “connecting” was identified in the
U.K. government’s Foresight Report as the first of five key actions that people
should take to improve their psychological well-being (Aked et al., 2008;
Foresight Mental Capital and Wellbeing Project, 2008). This public health
directive stated,
Connect . . . with the people around you. With family, friends, colleagues
and neighbours. At home, work, school or in your local community.
Think of these as the cornerstones of your life and invest time in devel-
oping them. Building these connections will support and enrich you every
day. (Aked et al., 2008, p. 5)
Mental Health Difficulties

Just as good interpersonal connections are associated with positive
psychological well-being, poor or absent interpersonal connections are asso-
ciated with the presence of mental health difficulties (Aked et al., 2008;
Eisenberger, Lieberman, & Williams, 2003; Hawkley & Cacioppo, 2010).
Indeed, distress related to interpersonal problems is one of the main rea-
sons why clients come to psychotherapy or counseling (Maling, Gurtman,
& Howard, 1995). For instance, one study suggested that about 75% of
clients—more than those not in psychotherapy (Maling et al., 1995)—had
goals for therapy in the interpersonal domain, a higher percentage than those
with symptom- or problem-specific goals (60.3%), personal growth goals
(45.9%), or well-being or functioning goals (13.4%; Grosse & Grawe, 2002).
Research has also suggested that psychotherapy clients have higher levels of
interpersonal difficulties.
This association with such difficulties holds for a range of mental health
issues, including, of course, loneliness, “one of the most common varieties
of mental distress in everyday life” (Reis, 2001, p. 64). People with depres-
sion, for instance, tend to have less intimate, less confiding, less responsive,
and more conflictual relationships; have less contact with friends; and, in
many cases, lack close relationships altogether (Birtchnell, 1999; Brown &
Harris, 1978; Coyne & Downey, 1991; Das-Munshi et al., 2008; Emmelkemp,
2004; Segrin, 2001). Similarly, “interpersonal factors are involved in various
stages in all of the anxiety disorders” (Alden & Regambal, 2010, p. 449), a
conclusion that holds true particularly for people with social anxiety, who
are likely to have lower levels of emotional intimacy in their close relation-
ships, experience lower perceived support, and be less likely to self-reveal
to others (Alden & Regambal, 2010). With respect to posttraumatic stress
disorder, meta-analytic research has indicated that a lack of social support is
one of the strongest predictors of difficulties (Nugent, Amstadter, & Koenen,
2011); similarly, with respect to bereavement and other life stressors for older
adults, the presence of a close, intimate confidant is associated with the main-
tenance of higher levels of morale (Baumeister & Leary, 1995). A lack of
perceived connection to others is also strongly implicated in suicidal desire,

with research indicating that a thwarted sense of belongingness and social
isolation are among the strongest and most reliable predictors of suicidal
ideation (Van Orden et al., 2010; You, Van Orden, & Conner, 2011).
Perhaps most surprising, the quality and quantity of interpersonal rela-
tionships are also one of the strongest predictors of mortality and physi-
cal health. Summarizing the evidence, Holt-Lunstad, Smith, and Layton
(2010) wrote,
Data across 308,849 individuals, followed for an average of 7.5 years,
indicate that individuals with adequate social relationships have a 50%
greater likelihood of survival compared to those with poor or insufficient
relationships. The magnitude of this effect is comparable with quitting
smoking and it exceeds many well-known risk factors for mortality (e.g.,
obesity, physical activity). (p. 14)
From Research to Practice

In summary, psychological evidence has indicated that individuals’ sense
of well-being and the extent to which they report close and supportive rela-
tionships in their lives are very strongly associated. This provides strong sup-
port for the humanistic psychotherapy hypothesis that experiencing a deep,
intimate encounter with a psychotherapist could, per se, have a strong positive
effect on clients’ psychological health and well-being. It may enhance clients’
levels of subjectively experienced happiness, provide some protection or ame-
lioration against such mental health difficulties as anxiety and depression, and
help clients meet their basic psychological need for relatedness (Ryan & Deci,
2000, 2002). It may also help clients develop their ability to relate more deeply
to others in their lives, hence extending and embedding these psychological
benefits.
These relationship processes may be particularly important in contem-
porary industrialized societies, in which a dramatic reduction in levels of
interpersonal connection appears to be occurring (Holt-Lunstad et al., 2010;
McPherson, Smith-Lovin, & Brashears, 2006). Between 1985 and 2002, for
instance, “the number of people saying there is no one with whom they discuss
important matters nearly tripled” (McPherson et al., 2006, p. 353); moreover,
although in 1985 modal respondents had three confidants, in 2002 they had
none. Of course, a psychotherapist is just one figure in an individual’s inter-
personal field, but the psychological research has suggested that the expe-
rience of even one strong attachment may make a considerable difference
compared with the experience of no close attachment—with diminishing
returns as the number of confidants increases (Baumeister & Leary, 1995). As
suggested above, it may also act as the catalyst for establishing a wider circle
of close relationships.
At present, however, this evidence of the importance of interpersonal
relationships has provided only tentative support to humanistic relational
practices, for two key reasons. First, evidence for the relationship between
psychological well-being and close interpersonal connections is primar-
ily correlational, such that it is not certain that the experience of closeness
with others actually causes improvements in psychological well-being (Reis,
2001). It may be, for instance, that people who are happier tend to form closer
relationships or that a third variable—such as level of extraversion, optimism,
or secure attachment—causes people to experience both greater well-being
and closer relationships with others (Diener & Seligman, 2002; Reis, 2001;
Uchino, 2009). In fact, evidence is beginning to emerge that suggests a specific
causal relationship from interpersonal connection to psychological well-being
(Kaniasty & Norris, 2008; Powdthavee, 2008; Reis, 2001; Stadler, Snyder,
Horn, Shrout, & Bolger, 2012; Uchino, 2009; Whisman & Baucom, 2012)—
particularly the experience of feeling understood (Reis, 2001)—but it is still
in its early stages. Second, even if this causal relationship can be established,
one must still be cautious about extending this research to the client–therapist
encounter. It may be, for instance, that the amount of time that clients spend
with psychotherapists is too limited to be of positive benefit or that clients
would discount experiences of intimacy and connection with their therapist
on the grounds that therapists are just doing their job.
Nevertheless, given the strength of the evidence linking interpersonal
relating to well-being, the humanistic hypothesis regarding the healing power
of the therapeutic relationship would seem to be highly plausible. It is also con-
sistent with the large body of psychotherapy research that has demonstrated
the importance of the psychotherapeutic relationship, as well as direct clinical
feedback, for clinical outcomes (e.g., Norcross, 2011).
An example of the latter comes from Sabine, a bright and friendly young
Asian woman who self-referred to a university psychotherapy clinic to help
overcome feelings of low self-esteem and worry, to resolve difficulties with
her mother, and to find the courage to pursue what she wanted to do. At
assessment, Sabine scored in the severe ranges for both generalized anxiety
(Generalized Anxiety Disorder seven-item scale) and depression (the nine-
item Patient Health Questionnaire) and was offered 24 sessions of humanistic
therapy in a pluralistic framework (Cooper & McLeod, 2011) by Mick Cooper.
This pluralistic approach meant that, although Sabine was primarily offered
an empathic and affirming relationship through which to find ways of moving
forward in life, several other methods were also introduced—by collabora-
tive agreement—into the psychotherapeutic work. For instance, in Session 2,
Socratic dialogue (Beck et al., 1979) was used to test out Sabine’s assumptions
about her mother; in Session 5, Sabine agreed to give herself some “worry
time” to concentrate specifically on her anxieties; and, in Session 19, focusing

(Gendlin, 1996) was used to explore Sabine’s feelings of sadness and anger
toward her mother. Sabine described each of these methods as helpful, but
when, in the final session, she summarized what had been most important for
her in the psychotherapeutic process, the relational aspects were what clearly
stood out. She stated,
I guess the biggest thing would be, um, acceptance, and you helped me—
made me feel really, sort of, welcomed into this, sort of, process. Um . . .
very early on in our sessions I remember just like going home, and just
like being really surprised—just thinking, “This guy gets me! He gets me,
he actually gets me,” and just like being really quite taken aback by that.
Um . . . ’cause it felt so new and so different. . . . The fact is that I’ve never
felt comfortable enough with anyone else. Um, and without that feeling
of being comfortable and being at ease, I don’t think—I don’t think this
process could have happened.
Sabine’s feedback highlights the value of such core humanistic relational
practices as empathic acceptance. However, the psychological evidence on
the salutogenic potential of relating may also provide a fertile ground in
which to stimulate new developments in humanistic theory and practice.
If, for instance, it is evident that people thrive best when they are in close
and supportive relationships, it may be that there is a role for developing
relational psychoeducation practices within the humanistic psychotherapies,
in which clients are helped to acquire skills in establishing more intimate
and rewarding connections with others. In the psychotherapeutic work with
Sabine, for instance, several sessions focused on letters she was receiving from
her mother and how she might respond in a constructive and assertive way. In
Session 22, for example, Sabine brought in a very long, detailed, and defen-
sive letter from her mother. In it, her mother justified the various behaviors
that Sabine, in a previous letter, had told her she found most difficult. The
dialogue proceeded along the following lines:
Mick: I wonder how it would be best to respond to this. What do you
think is best to do?
Sabine: It feels really important to show her how she is really misinterpret
ing things. You know, like she thinks that what she is doing is
totally normal, and it really isn’t—she needs to see that.
Mick: Yeah, I can see that, and how it ends up coming back at you
about being your problem if you don’t like how she’s behaving.
But I just wonder if—like, I’m just wondering—if you say to
her, “Look, your behavior is really wrong,” do you think that
might make her more defensive? Like she may even then try
and defend it further? I guess, if we look at this in terms of
responding assertively, what might be a more assertive response
is to really own your feelings and say something like, “Mum, when
you do that, it makes me feel really awkward and uncomfortable,”
and not go into whether it’s right or wrong. Not get into all
of that. Because, in a sense, she can’t argue with that. It is
your experience, and maybe you’ll get into less of an argument
about it and she might be less defensive and hear what it’s like
for you.
Sabine thought about this and decided that she would be better off directly
telling her mother how she felt.
This exchange with Sabine had more of a psychoeducational quality
than might be typical of some humanistic practices, but it was based on a
fundamentally humanistic understanding of what it means to communicate
in constructive ways: assertively, openly, and drawing from phenomenological
experiencing (Ornish, 1998). In this respect, although it is an example of
how the psychological evidence may stimulate humanistic psychotherapists to
consider different ways of working with clients, it is not about compromising
humanistic practices or values. Rather, what the psychological evidence may
do is to help humanistic psychologists identify and actualize different elements
of humanistic thinking, philosophy, or values that may, to date, have lain
dormant in the field.
Received Support
With respect to interpersonal relating, a second line of psychological

research potentially bears more critically on the practices of humanistic
psychotherapists. As we have shown, when human beings are asked to
report how much interpersonal closeness and support they have in their
lives, it tends to correlate positively with their levels of mental health and
well-being. However, when the actual amount of interpersonal support they
receive is directly measured—for instance, the amount of time they spent
talking to someone about their difficulties—it has been found, in several
studies, to correlate negatively with psychological well-being (e.g., Bolger,
Zuckerman, & Kessler, 2000; Rafaeli & Gleason, 2009). In one study, for
instance, “support receipt on a given day predicted subsequent increases in
anxiety, b = 0.12, p = .047” (Bolger et al., 2000, p. 956), particularly when
participants were under high levels of stress. Similarly, under these circum-
stances, “when recipients reported receiving support on a given day, the
change in their depression was 0.11 units higher than it was when they did
not report receiving support” (p = .024; Bolger et al., 2000, p. 957). In other
words, counterintuitively, the receipt of social support has been found to
correlate with “worse rather than better psychological outcomes” (Rafaeli
& Gleason, 2009, p. 22).

So does this mean that experiencing a supportive psychotherapy rela-
tionship has the potential to do more harm than good? Probably not; for a
start, this negative correlation may be because people who are experiencing
psychological difficulties are more likely to solicit social support from those
around them. Indeed, when examined longitudinally, received crisis support
has been found to be beneficial (Dalgleish, Joseph, Thrasher, Tranah, & Yule,
1996; Joseph, 1999). However, what a finer grain analysis of the research sug-
gests is that, under certain circumstances, acts that are intended as socially
supportive may not be experienced as helpful.
Visibility
Research has suggested that one of the principal reasons why this may be
the case is because the offer of social support has the potential to undermine
recipients’ feelings of self-worth, independence, and self-efficacy (Rafaeli &
Gleason, 2009; Shrout, Herman, & Bolger, 2006; Uchino, 2009). It may also
create a sense of indebtedness to the supporter, drawing the recipient’s atten-
tion to his or her problems (Rafaeli & Gleason, 2009).
In this respect, a series of studies have suggested that, although visible
support (i.e., support that the recipient is aware of receiving) is associated
with increases in psychological distress, invisible support (i.e., support that a
provider reports giving but that the recipient is not aware of receiving) is asso-
ciated with reductions in psychological distress (Bolger et al., 2000; Howland
& Simpson, 2010; Maisel & Gable, 2009; Shrout et al., 2006). Here, visible
support consists of overt, recognizably supportive transactions. By contrast,
invisible support is covert, equal, and conversation-like; it deemphasizes the
supporter and supportee roles. It also deflects away from the supportee’s prob-
lems to discuss difficulties in a third-person or self-focused context (Howland
& Simpson, 2010). So visible support might be when a friend says to you,
“Let’s talk about your problems,” whereas invisible support might be when
a friend casually chats to you about problem areas in your—and perhaps his
or her—life, without making it explicit that this is intended for your benefit.
What the research has suggested is that, in some respects, the latter may be
more helpful than the former because it is less likely to leave you feeling needy
or to dent your sense of self-worth.
Mutuality
Consistent with the research on invisible support and the need to main-
tain positive self-worth, Gleason, Iida, Shrout, and Bolger (2008) found that,
on average, the receipt of support does not have a negative effect if an indi-
vidual is providing support to the other at the same time—that is, if the provi-
sion of support is mutual rather than one way. More specifically, Gleason et al.
found that individuals tend to feel most negative when they are receiving
support and not providing it and least negative when they are both receiv-
ing and providing support. This finding would seem to be consistent with
Baumeister and Leary (1995), who reported that “love is highly satisfying
and desirable only if it is mutual” (p. 514). That is, people who gave love
without receiving it, and received it without giving it, tended to describe the
experience as aversive.
Responsivity
Another reason why attempts to be supportive may be associated with
higher distress is because, in some instances, such attempts may be unrespon-
sive to the actual needs and wants of the supportee (Maisel & Gable, 2009;
Rafaeli & Gleason, 2009; Uchino, 2009). For instance, emotional support
seems to be more helpful when events are uncontrollable, whereas instru-
mental, practical support seems to be more helpful when circumstances can
be changed (Rafaeli & Gleason, 2009; Shrout et al., 2006; Uchino, 2009).
Hence, if a supporter is offering practical advice to a supportee when nothing
can be done—that is, support that is unresponsive to the situation—it may
increase such negative feelings as helplessness and not being understood.
Skillfulness
Finally, it may also be that the kinds of support that people are providing—
albeit well intentioned—are simply not very skillful (Bolger et al., 2000).
For instance, it seems important that support be given in a noncritical way
(Rafaeli & Gleason, 2009). Similarly, research has suggested that interper-
sonal support may be most helpful when the supportee feels understood, valued,
and cared for (Maisel & Gable, 2009).

The psychological research into received support, and the factors that
determine its impact, provides some valuable pointers for effective human-
istic practice. First, it suggests that humanistic psychotherapies may be most
beneficial when they are responsive to the particular needs and wants of
an individual client. As we have shown, for instance, if clients are facing
uncontrollable circumstances, providing them with emotional support may
be most appropriate, and more practical and psychoeducational support may
be more helpful if there are specific things that clients can do to change
their circumstances. In the humanistic psychotherapies field, several mod-
els of practice now emphasize this process of personalizing the therapy to the
client’s particular preferences and wants (e.g., Cain, 2010; Cooper & McLeod,
2011; Duncan, 2010). These models highlight the value of metatherapeutic

communication (or shared decision making; Cooper & McLeod, 2012)—
that is, talking to clients about what they want and prefer in therapy—and
the use of outcome and process measures to support an ongoing process of
client feedback across the client’s therapeutic journey.
An example of this comes from a series of psychotherapeutic episodes
with a young poet, Dane. Dane was in the second year of his English language
degree when he first self-referred to a university research clinic, where he was
seen by Mick Cooper. Dane met the criteria for social anxiety but presented
himself in a very confident way, bordering on brash. Indeed, Dane finished
many of the first psychotherapy sessions saying that he was not really sure
whether the therapy was helpful, wondering aloud whether he would return.
Mick encouraged Dane to explore this with him, but throughout this first
episode of therapy, Mick tended to be rather quiet with Dane, often spending
long periods of time listening to Dane talk. Mick discussed this in supervision,
exploring whether he felt intimidated by Dane or whether he sometimes
struggled to follow where Dane was going with his narrative.
Dane completed his therapy after the 20 sessions offered, but approxi-
mately 1 year later, he recontacted Mick to see whether it was possible to con-
tinue the work. Dane wanted to look at developing more balanced relationships
with others and to stop being so bullish, aggressive, and intimidating. As part of
this reassessment, Dane was asked to complete a Therapy Personalization Form
(Bowens & Cooper, 2012), which invited him to indicate what he wanted in
therapy. Would he like, for instance, more focus on his past or his present?
Would he like the therapist to be more formal or to adopt a more friendly and
personal stance? A consistent message in Dane’s responses—and in the con-
versation that followed afterward—was that Dane wanted more challenge from
Mick—more focus, interruption, and direction—along with an opportunity to
explore in greater depth the relationship between them.
As a consequence of this feedback, Mick pushed himself to be more
active and present with Dane: sitting forward rather than sitting back in the
psychotherapeutic work. If he was getting lost following Dane’s narrative, for
instance, he was much quicker to express it; he encouraged Dane to talk about
issues that Dane had flagged as important to him; and he brought more of his
reactions to Dane into the psychotherapeutic work. Although initially this
way of engaging felt somewhat counterintuitive to Mick, Dane consistently
reported that he was finding this work more stimulating and helpful.
For humanistic psychotherapists, however, perhaps the most challeng-
ing finding in this area of research may be that the provision of interpersonal
support has the potential to be detrimental if it is experienced as highly visible
and nonmutual. This is challenging, because humanistic psychotherapies—
as with most other forms of psychotherapeutic practice—are about as visible
and nonmutual as a supportive interpersonal relationship can be. Here, the
client is specifically identified as the one coming to the psychotherapist for
help, there is rarely mutuality of support, and the client’s difficulties are
typically given priority as the principal focus of the psychotherapeutic work.
Clearly, these aspects of the psychotherapeutic enterprise are there for good
reason. However, if the psychological evidence can be transposed to the
psychotherapeutic arena, it would suggest that some clients may experience
a drop in self-worth, independence, and self-efficacy just by virtue of being
psychotherapy clients.
Given that the humanistic psychotherapies are consistently associated
with client benefit (Elliott, Greenberg, Watson, Timulak, & Freire, 2013),
it seems likely that any detrimental effects would be offset by more positive
aspects of the humanistic psychotherapy process. However, this psychological
research does point to the potential advantages of humanistic psychotherapies
in which interpersonal support is provided in a more mutual, nonvisible
ways, for instance, group psychotherapy (e.g., Spiegel, Bloom, & Yalom,
1981), cocounseling (Kauffman & New, 2004), or peer support (Cowie,
2000). Even in more traditional psychotherapeutic formats, however, there
may still be ways in which humanistic psychotherapists can decrease the
visibility and one sidedness of the support process without compromising
the integrity or focus of the therapeutic work. For instance, in certain cir-
cumstances, it may be appropriate for therapists to share their vulnerabilities
(L. H. Farber, 2000; Spinelli, 1994), to disclose how they have experienced,
or do experience, some of the same psychological difficulties as their client
(Cooper, 2015), or to actively challenge the imbalance of status in the thera-
peutic relationship.
After completing his degree, for instance, Dane spent a number of
months becoming increasingly anxious about where he was going in his life.
With his psychotherapist, Mick, he explored his feelings about this as well
as the kinds of work that might give him a sense of meaning and purpose.
In a few sessions, however, Mick also disclosed how much he had struggled
at a similar point in his life, which was something that Dane described (on
postsession feedback forms) as useful, in that it helped depathologize his
feelings of anxiety. In many of the psychotherapeutic sessions, Mick and
Dane also explored the power dynamic between them and how Dane tended
to project authority onto Mick as well as others in his life. Consequently,
he would act deferentially, but then feel belittled and angry, and end up
acting in aggressive and critical ways. Here, again, Mick would sometimes
disclose his vulnerability to Dane—for instance, that when they first worked
together he had felt intimidated and anxious that he was not doing his job
well enough—and he also challenged Dane to take more authority in the
psychotherapy relationship: to acknowledge his strengths, abilities, and
capacities.

A verbatim example of this revolved around a poster that Mick had
bought for the consulting room, which had a few lines of poetry on it. Dane,
being a poet, noted this and commented somewhat disparagingly on the
cheesiness of the poem. Mick invited Dane to say more—to be the authority
in the room and to explain to Mick why this poem was tacky—but Dane was
not forthcoming. Several sessions later, as they discussed the way in which
Dane tended to give away his authority to others, they came back to it, and
this time Dane took up the challenge:
Mick: I think something I’m really struck by is that you’ve never told
me—I remember asking you—to teach me why that’s a crappy
poem [laughs], and you still haven’t done that. And I think there’s
something about . . . I remember talking about that and saying,
“Actually . . . with that poem, you know much more than I do.”
Dane: Yeah . . . it feels weird in terms of like . . . I’m quite a technical
person and I do have these practical skills. . . . [Dane goes on to
explain, technically, some of the problems with the poem.] It doesn’t
really feel sensitive or considered. . . . It doesn’t feel natural,
it’s like—there’s something a bit. . . . sort of formal . . . formally
composed, but quite awkward about it. . . . It’s not dealing with
that subject in a complex way that—that engages that as the
subject matter. [Pause]
Mick: How does it feel . . . to kind of . . . to talk to me about something
in a way that . . . in that way? How does it feel to say that to me
about that poem?
Dane: I guess a little bit . . . I don’t know. I feel a little bit anxious
about that.
Mick: Why are you anxious about that?
Dane: I guess you are feeling attacked by it.
Mick: I mean, my experience . . . I think it’s really interesting what
you are saying. It helps me to see it [the poem] in a different
way. Didn’t feel attacked at all. Didn’t feel critical. Felt really
interesting.
Dane: Mmm . . . But I guess I feel like you’ll feel attacked, and you’ll
attack me back.
Mick: I know. Yeah . . . yeah. . . . It is really interesting what you say
about the poem. I guess the important bit here is around that
anxiety that if you share with me your knowledge and your exper-
tise, and something which is at a level beyond . . . my expertise,
that you know more about that than I do. Then there’s some-
thing about you feeling that you have to hold that back.
Dane: Yeah.
Mick: Or, kind of, yeah . . . that it’s difficult for you to put that out
there. And I think that crosses lots of situations.
Dane: Yeah.
In this example, then, Dane was encouraged to be more than just a recip-
ient of psychotherapeutic support, but also an expert who could know more
about some things than his psychotherapist. The traditional psychotherapist–
client power relationship was temporarily subverted; from the psychological
evidence, it would seem that this might be an important process in supporting
a client’s sense of competence and self-worth. As can be seen in this example,
it also provided a valuable opportunity for the client to explore in more detail
the dynamics of his relationships in everyday life.
VALUE OF EMOTIONAL EXPRESSION AND PROCESSING
“One of the most distinguishing features of humanistic therapies,” wrote

Cain (2002, p. 10), “is their emphasis on the importance of emotions.” With
their emphasis on holism and the “self-righting” nature of human beings
(Bohart & Tallman, 1999), humanistic therapies view emotions as part of
the human being’s inherent propensity to respond adaptively to the world.
Hence, across the humanistic therapies, clients are encouraged to express
and make sense of (i.e., process) their emotions, feelings, and felt senses,
whether in the nondirective space of a client-centered relationship (Rogers,
1951) or through the more active strategies of emotion-focused (Greenberg,
Rice, & Elliott, 1993), focusing-oriented (Gendlin, 1996), or Gestalt (Perls,
Hefferline, & Goodman, 1951) therapies.
Emotional expression can be defined as “observable verbal and non-
verbal behaviors that communicate and/or symbolize emotional experience”
(Kennedy-Moore & Watson, 1999, p. xv). Being able and willing to express
one’s emotions is a key component of engaging intimately with others (Aron,
Mashek, & Aron, 2004; Fehr, 2004; Prager & Roberts, 2004), receiving social
support, and relating to the world in an authentic way (see Being Authentic
section). As in humanistic models of therapeutic change, there is a wide-
spread public belief that it is important for people to be able to talk about
their feelings (Brownlie, 2011). Indeed, “most people feel a compelling need
to talk with others about emotional upheavals, negative life events, and
important aspects of their identity” (Major & Gramzow, 1999, p. 736). What
does the psychological evidence actually say about the value of emotional
expression?

Self-Disclosure
Much of the work pertaining to this question comes from research into
self-disclosure, which includes—but is not limited to—the disclosure of feel-
ings and affect (for research on disclosure in the psychotherapeutic relation-
ship, see B. A. Farber, 2006). Pennebaker’s (1997) program of research into
written emotional expression is of particular importance here. In his basic
research design, participants were randomly distributed to one of two writing
conditions: one in which they were asked to spend 15 to 30 minutes per day,
for 3 to 5 days, writing about their deepest thoughts and feelings and about an
extremely important emotional issue that affected them, and a control condi-
tion in which they were instructed to spend the same amount of time writing
about something more superficial (Pennebaker, 1997). Pennebaker’s studies
found that writing about emotional topics brought about significant reduc-
tions in psychological distress, as well as improvements in physiological func-
tioning, such as antibody levels against hepatitis B (Petrie, Booth, Pennebaker,
Davison, & Thomas, 1995), with a mean effect size equivalent to a Cohen’s d
of about 0.15 (Frattaroli, 2006). Although this effect size would be classed as
small, one should bear in mind that many of these interventions were very brief,
and studies with longer periods of disclosure, or more instances of disclosure,
have demonstrated significantly larger effect sizes. It is interesting, how-
ever, that studies that have compared writing versus talking to a therapist or
a tape recorder have found comparable biological, mood, or cognitive effects.
Receiving feedback from others does not seem to enhance the effectiveness of
the procedure (Pennebaker, 1997).
Self-Concealment
The opposite of self-disclosure is self-concealment, defined as the “pre-

disposition to actively conceal from others personal information that one
perceives as distressing or negative” (Larson & Chastain, 1990, p. 440).
Across a range of studies, it has consistently been demonstrated that people
who conceal more have higher levels of psychological—and physiological—
difficulties, such as greater anxiety and depression, as well as rumination and
loneliness (Kelly & Yip, 2006; Larson & Chastain, 1990; Uysal, Lin, & Knee,
2010). This finding has also been demonstrated in relation to specific life
events. For instance, those with more positive attitudes toward emotional
expression seem to do better after disaster than those with more negative atti-
tudes (Joseph et al., 1997); similarly, not telling others about one’s abortion
has been shown to be associated with greater psychological difficulties (Major
& Gramzow, 1999). Indeed, research has even shown that self-concealment
has effects on health, with gay men who are completely out of the closet less
likely to experience cancer and infectious diseases than those who conceal
their sexuality (Cole, Kemeny, Taylor, & Visscher, 1996).
As with the research on self-disclosure, such evidence could be read as
supporting humanistic psychotherapeutic practice and its emphasis on facili-
tating emotional expression. However, the correlational nature of these find-
ings means that causation cannot be established. In particular, rather than
self-concealment causing psychological distress, it may be that people with
a generally open, nonconcealing personality type also tend to experience
greater well-being. Here, Kelly and Yip (2006) distinguished between being
a secretive person and keeping a secret, providing evidence that, although
the predisposition to keep secrets is associated with higher symptom
atology, the actual act of keeping a secret may be associated with a lowering
of distress.
In fact, more recent research has suggested that self-concealment, both
as a personality trait and as a daily activity, is associated with reduced well-
being (Uysal et al., 2010). However, Kelly and Yip’s (2006) challenge to the
assumption that self-concealment is inherently harmful—alongside other
evidence that emotional expression is not always beneficial (e.g., Stroebe,
Stroebe, Schut, Zech, & van den Bout, 2002)—indicates that the disclosure
of emotional experiences is not a ubiquitously positive activity. In attempting
to understand, therefore, when and where it might be beneficial, it is impor-
tant to examine the specific mechanisms by which emotional expression
might bring about positive change.
Why, and Under What Conditions, Is Emotional Expression Beneficial?
So how might emotional expression be of benefit to people, and what

might this indicate about the conditions within which it would be most
beneficial?
Reduction in Physiological Strain

A principal explanation for why the disclosure of emotions is helpful
is that it reduces the strain of hiding them from self and others. More spe-
cifically, researchers have argued that the act of self-concealment requires
physiological effort, which then serves as a long-term, low-level stressor, pre-
disposing the individual to psychological as well as physical problems (Larson
& Chastain, 1990; Major & Gramzow, 1999; Uysal et al., 2010). If this is the
case, then individuals who have a strong desire to express themselves, or a
predisposition to or preference for a high level of self-disclosure (Alexopoulos,
Raue, & Areán, 2003; Kennedy-Moore & Watson, 1999), may be particu-
larly likely to find relief through emotional expression.

Reduced Preoccupation
Closely connected to reduction in physiological strain, researchers have
also hypothesized that self-concealment can have negative consequences
because, paradoxically, it leads people to become more focused on—and aware
of—the feelings and experiences that they are trying to suppress (Uysal et al.,
2010). These feelings and experiences may then be experienced as intrusive
thoughts (Major & Gramzow, 1999) and can undermine people’s basic needs
for feeling autonomous and in control of their world (Uysal et al., 2010).
Processing Emotion
Expression of emotions may also be important, because, through articu-
lating and talking about their deeper feelings, people may come to learn more
about themselves—for instance, the way in which they perceive the world,
their organismic wants, and the situations that trigger distressing emotions.
Through this experience, they may then find ways of being in the world that
are more satisfying and fulfilling. This view is consistent with the psychological
research that has shown that emotional catharsis, in itself, is inadequate for
producing positive change—it needs to be combined with some cognitive
processing of the emotion (Bohart, 1980; Kennedy-Moore & Watson, 1999).
For example, venting anger is most likely to be helpful when it “results in
changes in the perception of the expresser or the behavior of the target”
(Kennedy-Moore & Watson, 1999, p. 41)—that is, when it helps the person
to resolve the source of the anger. Indeed, when asked why writing about a
trauma was beneficial, 75% referred to insight, with just 10% focusing on the
purging of emotions (Kennedy-Moore & Watson, 1999).
As well as helping people transform their way of being in the world,
emotional processing may also be beneficial because it can reduce people’s
confusion about unclear emotions and their source, hence reducing levels of
distress. Kennedy-Moore and Watson (1999) wrote, “Poor understanding of
one’s feelings increases the chance of being caught in an aversive ruminative
process, trying to figure out one’s internal state” (p. 78).
Allowing Thoughts to be Challenged

Along with developing self-awareness, emotional expression and pro-
cessing may also be important because they allow an individual’s assumptions
about the emotion, and the experiencing of it, to be challenged in several
ways. First, it may provide the individual with an opportunity to question
the assumptions and core beliefs that underlie the emotion. For instance,
self-disclosure is linked to reduced posttraumatic stress symptoms (Alden
& Regambal, 2010), perhaps because, by talking through the problem, the
individual can develop a more congruent understanding and memory of
the trauma. Similarly, “reduced self-disclosure is thought to be particularly
detrimental to [obsessive–compulsive disorder] as it prevents individuals
from gathering information to challenge their catastrophic interpretations”
(Alden & Regambal, 2010, p. 457).
Second, disclosure of emotions may help individuals challenge their
perception that there is something bad, shameful, or wrong in the emotion
that is being concealed (Uysal et al., 2010), particularly if they are talking
it through with positively regarding others. Third, if individuals conceal
an emotion because they are afraid of being overwhelmed by its expres-
sion, disclosing it in a safe and containing environment may help them
to recognize that its expression is tolerable (Kennedy-Moore & Watson,
1999), which may then reduce feelings of fear and apprehension toward
the emotion.
From the psychological evidence, there are good grounds to believe

that, in many instances, helping clients express their emotions is of psycho-
logical benefit. The research has provided generally good support for the prac-
tice of humanistic psychotherapies. However, evidence that self-disclosure
and a lack of self-concealment are associated with psychological well-being
cannot be taken as evidence that emotional disclosure facilitates well-being;
indeed, it seems likely that, even with the most accepting and empathic psy-
chotherapist, there will be conditions under which it may not be helpful for
individuals to disclose how they are feeling. More specifically, on the basis of
the psychological evidence, it can be hypothesized that emotional expression
may be most helpful in psychotherapy when clients
77 are experiencing a lot of strain from concealing how they feel
from others;
77 have a strong desire to express something;
77 are typically people who benefit from expressing themselves;
77 are preoccupied with the emotions that they are concealing or
are experiencing intrusive thoughts;
77 can reflect on, process, and learn from their emotions to find
more effective ways of engaging with their world;
77 are confused or overwhelmed by their emotions;
77 have emotional responses that are based on misunderstandings
or misperceptions of their world;
77 feel that their emotional responses are bad, shameful, or wrong;
and/or
77 are afraid that their emotions are not tolerable.

These factors may explain why Sabine, introduced earlier, found it help-
ful to have an opportunity in psychotherapy to express and make sense of
her emotions. She was someone who loved talking to others but felt that
there were certain areas of experiencing—such as her feelings toward her
mother—that she did not want to burden others with. Partly, this was because
of the shame and guilt she felt at experiencing such anger and anxiety, given
that this was not what good, normal daughters felt. Although Sabine had
tried hard to push these feelings away, her anger toward and anxiety about
her mother seemed to return consistently, to the point at which these feelings
could sometimes seem unbearable. By expressing her emotions in an empathic
and accepting psychotherapeutic environment, Sabine came to feel less
ashamed and guilty about them, less bottled up, and more in control of her
psyche. In subsequently processing—and learning from—these emotions, she
could also find ways of changing her behavior toward her mother that would
lessen the likelihood of their recurrence. Had Sabine, however, been someone
who felt fine about her emotions toward her mother and had many people to
share this with, the value of emotional expression in psychotherapy might
have been substantially attenuated.
Drawing the evidence together, Uysal et al. (2010) suggested that the
key issue is whether self-concealment thwarts individuals’ ability to attain
their basic psychological needs for autonomy, competence, and relatedness
(Ryan & Deci, 2000). If concealing their emotions, for instance, leaves indi-
viduals feeling confused, then their sense of autonomy is likely to be compro-
mised; if it compounds feelings of shame, then their need for competence may
be undermined. Similarly, if individuals feel more isolated because they are
not expressing their genuine feelings to another, then this may compromise
their need for relatedness. Empirical research has provided strong support
for this mediating role of basic need satisfaction (Uysal et al., 2010), suggest-
ing that the key question for humanistic psychotherapists may be whether
emotional disclosure help clients achieve more of their basic needs. That is,
will it help them feel more in control of their lives, better about themselves,
and closer to others?
BEING AUTHENTIC
A third, interlinked construct that cuts across theories of humanistic

psychotherapy is authenticity. All humanistic therapists, regardless of their
particular orientation, are concerned with helping people lead more authen-
tic lives. Authenticity refers to a person’s ability to be mindful and emotionally
literate in relation to his or her thoughts and feelings and to behave in ways
that are consistent with those thoughts and feelings.
Despite this consensus, the construct of authenticity has received little
empirical research attention until recently. A little more than a decade ago,
Harter (2002) commented that “there is no single, coherent body of litera-
ture on authentic self-behavior, no bedrock of knowledge” (p. 382). Since
then, the past decade has seen authenticity become the focus of much new
research by personality, developmental, and positive psychologists (Harter,
2012). Several psychometric tests developed in this period have led to
research interest. We describe two such measures that have attracted inter-
est next.
Psychometric Scale Development
First, the Authenticity Scale, developed by Wood, Linley, Maltby,

Baliousis, and Joseph (2008), consists of 12 items and is scored to yield three
4-item subscales: Resisting External Influence (e.g., “I usually do what other
people tell me to do”), Self-Alienation (e.g., “I feel as if I don’t know myself
very well”), and Authentic Living (e.g., “I always stand by what I believe in”).
Each item is rated on a 7-point scale ranging from 1 (does not describe me at
all) to 7 (describes me very well). By this definition, which was derived largely
from person-centered theory, authentic people know themselves and their
motivations, are able to stand up against social pressures, and speak the truth
as it appears to them.
Second, the Authenticity Inventory, developed by Kernis and Goldman
(2006), consists of 46 items, grouped into four scales: Awareness of Oneself
(e.g., “I am often confused about my feelings”), Unbiased Processing of
Information Relevant to Ourselves (e.g., “I find it very difficult to critically
assess myself”), Behavior (e.g., “I am willing to change myself for others if
the reward is desirable enough”), and Relations With Others (e.g., “I make
it a point to express to people who are close to me how much I truly care for
them”). Respondents are asked to rate how much they agree with each item
on a 5-point scale ranging from 1 (strongly agree) to 5 (strongly disagree).
Well-Being and Mental Health
For humanistic psychotherapists, the concept of authenticity is often seen

as a goal of therapy worth attaining in its own right. Greater authenticity is also
assumed to be related to greater well-being and fewer mental health difficulties.
Using the scales mentioned above and other such measures, several studies
have been carried out over the past few years to test this latter hypothesis. They
have shown that, on average, people who score higher on tests for authentic-
ity are more satisfied with life, higher in self-esteem, less depressed and anx-
ious, and more alert and awake. They also have fewer physical symptoms such

as headaches, aches, and pains (e.g., Goldman, 2006; Goldman & Kernis,
2002; Kernis & Goldman, 2006; Lakey, Kernis, Heppner, & Lance, 2008;
Wood et al., 2008).
To test whether authenticity specifically leads to well-being, Kifer, Heller,
Perunovic, and Galinsky (2013) randomly assigned participants to one of two
groups. Group 1 was instructed to recall and write about a situation in which
they were true to themselves and behaved in accordance with their true
thoughts, beliefs, personality, or values, and Group 2 was instructed to recall
and write about a situation in which they were inauthentic. Immediately
afterward, participants completed a measure of happiness. Results showed
that those asked to recall being authentic were happier than those asked to
recall being inauthentic (Kifer et al., 2013). Other studies have found that
when people’s life goals are thematically consistent with their personality
traits, they are happier (McGregor, McAdams, & Little, 2005). Research has
overwhelmingly indicated that authenticity is related to increased well-being
and better mental health.
One possible explanation for why authenticity is related to well-being
is that it enhances meaning in life. Schlegel, Hicks, Arndt, and King (2009)
asked participants to take part in an experiment. Their first task was to circle
on a list of 60 descriptive words (such as warm, friendly, and outgoing) 10 that
described their true self, defined to participants as “those characteristics that
you possess and would like to express socially, but are not always able to, for
whatever reason. Think of only those traits that you are able to express around
those people you are closest to.” Participants also completed a questionnaire
designed to measure the extent to which they had meaning in their lives. To
assess how well participants knew themselves, they were given a computer task.
Words from the original descriptive list were presented on the screen, and par-
ticipants were asked to respond as quickly as possible to each word by pressing
either a button labeled me or one labeled not me. What the researchers found
was that those who were fastest at correctly identifying “me” had the highest
scores on meaning in life (Schlegel et al., 2009).
More authentic people are also hypothesized to be more mindful. In one
study, Lakey et al. (2008) found that those higher on authenticity were less
defensive. The explanation for this was that authentic people were more mind-
ful. Authentic people, they showed in further analysis, were more able to focus
their attention and awareness on immediately present stimuli in a nonjudg-
mental manner (Lakey et al., 2008).
Social Functioning
A recent topic for research was the association between authenticity and
social functioning. Pinto, Maltby, Wood, and Day (2012) asked participants
to engage in a computer task in the laboratory that involved participants
pressing a button in relation to a message that appeared on the screen. If
they pressed a certain button in the time allocated, the participants earned
points that they could exchange for money. Participants were told that they
were playing against another person in an adjoining laboratory who could
steal points from them. The task was designed to mirror real-life situations in
which people may sometimes take credit for others’ hard work.
However, the experiment was rigged, in that participants were not actu-
ally playing against another person. It was designed so that participants would
think that someone else was stealing points from them. The idea was that
participants would feel cheated and provoked to play the game aggressively.
To test whether they would behave aggressively, participants were told that
they could steal points from their opponent next door if they wanted. Pinto
et al. (2012) found that players high on the Authenticity Scale were actually
less likely to respond aggressively—they continued to do their best to earn
points for themselves rather than turning their attention to getting their
own back. Those high on the Authenticity Scale were, in short, less punitive
toward others.
It has also been hypothesized that authentic people’s relationships are
more intimate. Swann, De la Ronde, and Hixon (1994) surveyed 176 mar-
ried and dating couples. Partners were seated at the opposite ends of a long
table, so that they could not see each other’s answers, and asked to complete
a questionnaire describing first themselves and then their partner. Whereas
dating people were most intimate with partners who evaluated them favor-
ably, married people were most intimate with spouses whose evaluations
mirrored their own self-ratings. This was true regardless of whether spouses
rated themselves negatively or positively. This finding is consistent with the
hypothesis that, as relationships deepen, people want to be known for who
they are.
Neff and Suizzo (2006) asked people to rate the relationship between
them and their partner in terms of who has the most say. Participants were
asked to rate the level of equality in their relationship on a 5-point visual
scale ranging from dominant through equal to submissive. Those who per-
ceived themselves to be in a subordinate relationship were more likely to
admit that they acted phony with their partner and felt less able to be
themselves.
Lopez and Rice (2006) identified two key components of authentic rela-
tionships. The first was unacceptability of deception (e.g., “I would rather be
the person my partner wants me to be than who I really am,” a negative item)
and the second was intimate risk taking (e.g., “I share my deepest thoughts
with my partner even if there’s a chance he/she won’t understand them”).

They found that those who scored highest on both these dimensions were
most satisfied with their relationship, even controlling for gender, self-esteem,
commitment level, and adult attachment style.
As with relational closeness and emotional openness, overwhelming evi-

dence has indicated that authentic being is associated with positive mental
health and well-being. And although, again, one needs to be cautious not to
interpret correlation as causation, emerging evidence (such as the Kifer et al.,
2013, study) has suggested that authentic being can lead to improvements in
psychological happiness. Hence, the humanistic psychotherapy goal of facili-
tating authenticity would seem to be supported by the psychological evidence.
Indeed, this evidence serves as a reminder to all therapists about the core
values and direction of humanistic therapy practice.
In the work with both Sabine and Dane, finding more authentic ways of
being was a critical element of their development in psychotherapy. For Dane,
it involved “standing out from behind his mask,” as he put it, and encounter-
ing others with more of his passion, vulnerability, and uniqueness up front. It
also meant discovering what was truly meaningful for him; indeed, in the last
year of therapy, Dane became increasingly involved in community writing
projects, where he could use his language skills to help others develop theirs.
For Sabine, becoming more authentic meant standing up to her mother and
others in her life and recognizing that her own needs and wants were as legiti-
mate in relationships as those of others.
A third psychotherapy client, Fiona, gave a vivid description of this
movement toward greater authenticity. In her final session with Mick, she
read out a fairy tale that she had written to describe her therapeutic journey.
This session was the culmination of several years of working together, in
which Fiona had moved away from a dependency on the approval and judg-
ments of others toward a deep trust in her own wisdom. The story reads as
follows:
Once upon a time, long ago and far away, there lived a young woman.
This was no ordinary young woman, for she was made of mirrors and glass
that sparkled and shone in the sun.
Everybody loved the young woman, for with her brightness she was
very beautiful, and with her mirrors she reflected everything that was
wanted of her. She had the magical gift of giving each person exactly
their heart’s desire.
But inside the sparkling mirrors and the shining glass the young
woman was very, very small, much too little to carry the mirrors’ weight.
“I am so tired,” she said. “Whenever someone wants me to be this per-
son, then someone else wants me to be that person, and another one
wants me to be another person, and it just goes on and on until there is
nothing left of me except the mirrors and the glass and they are so very
heavy to bear.”
And the young woman sat down and wept. And as she wept her tears
ran down the mirrors and the glass.
And the years passed, and the young woman grew older, and still she
wept. And she had three beautiful children, and still she wept. And those
children had children, and still she wept and still the tears ran down
the mirrors and the glass.
But this was no ordinary woman, as we said before, and she knew
that each of her tears held a tiny drop of magical transformation. So her
weeping slowly worked away at the mirrors and the glass. And the more
she wept, the greater the transformation.
Then very extraordinary people came who looked right through the
glass and the mirrors, and a most curious thing came to pass—the mirrors
and the glass started to dissolve. They became thinner and thinner and
weighed less and less.
And then another most curious thing happened—the thinner the
mirrors became, the taller the woman grew; and the lighter the glass
became, the stronger the woman grew, until the mirrors and the glass
were like gossamer, and the woman was tall and strong.
Then the woman stood up, and dried her tears, and laughed a great
shout of laughter. And the last of the mirrors and the last of the glass
shattered and were blown into nothingness.
And the woman stretched out her hands to the world, stepped out
onto the path, and walked away laughing.
Fiona’s story not only illustrates this movement toward authenticity and
its psychological value, but also the way in which emotional expression (the
young woman’s tears) and a deep therapeutic connection (someone who looked
right through the glass) were key to facilitating this process.
However, the psychological evidence regarding the salutogenic poten-
tial of authenticity can also encourage humanistic psychotherapists to con-
sider other ways in which they might support clients in this direction: For
instance, might there be psychoeducational, perhaps web-based, methods
that could support individuals in developing their authenticity? In addition,
the development of valid and reliable measures of authenticity indicates that
humanistic psychotherapists can gain the confidence to use such measures in
their own practice, research, and outcome evaluations. In terms of practice,
individual practitioners may find the use of measures of authenticity consis-
tent with their own needs for outcome measurement and more suitable than
traditional measures of psychopathology.

CONCLUSION
In this chapter, we reviewed the psychological evidence in relation to

three key humanistic psychotherapy assumptions: that a close, supportive
interpersonal connection has healing potential, that it is helpful for people
to express and process their emotions, and that being authentic can lead to
greater psychological well-being.
Through this review, we hope to have achieved three things. The first
is to demonstrate that some of these key assumptions underpinning humanis-
tic psychotherapy practice are firmly grounded in the contemporary psycho-
logical evidence. As we have shown, the evidence is now overwhelming that
positive psychological well-being is associated with close interpersonal rela-
tionships, emotional openness, and authenticity, and although much of this
evidence remains correlational, indications are emerging that the latter three
conditions are all directly able to facilitate well-being. These findings are
consistent with psychotherapy research findings in such areas as the thera-
peutic relationship (Norcross, 2011) and self-disclosure (B. A. Farber, 2006),
enhancing the support for humanistic models of practice. Second, we hope
to have shown that psychological evidence can help us develop and refine
humanistic psychotherapeutic practices—identifying, for instance, forms
of psychotherapeutic support in which there is greater mutuality. Third, we
hope to have indicated some of the psychological evidence bases that can
be drawn on to ground, and nourish, humanistic psychotherapy practices,
in particular those from positive psychology (e.g., Linley & Joseph, 2004),
developmental psychology (Harter, 2012), and personality and social psy-
chology (e.g., Gleason et al., 2008).
Reconnecting humanistic psychotherapy to a set of psychological roots
has both outward- and inward-facing advantages. It allows us to demonstrate
to others the strength and value of what we do. It shows that humanis-
tic psychotherapies are based on some of the best-established facts in the
field of scientific psychological inquiry. As we have seen, for instance, the
humanistic emphasis on developing a close and supportive psychotherapeutic
relationship is powerfully supported by evidence that such relationships
are one of the best predictors of psychological well-being. Indeed, given
how important it is for people to feel closely connected to others, it may
seem nonsensical to develop psychotherapeutic procedures in which such
a relationship is not strongly emphasized. Yet, perhaps more important,
reconnecting to a set of psychological roots can help the humanistic psy-
chotherapies grow and evolve in yet more innovative and creative ways.
Psychological research has the power to stimulate and inspire us in ways
that can keep us grounded in a bedrock of empirical realities. In this
respect, it is a highly fertile source.
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II
Overviews of Research
2
EFFECTIVE HUMANISTIC
PSYCHOTHERAPY PROCESSES
AND THEIR OUTCOMES
MICHAEL J. LAMBERT, LOUISE G. FIDALGO,
AND MADELINE R. GREAVES
In this chapter, we summarize research on psychotherapies that are part

of the humanistic tradition (see Cain & Seeman, 2002). Clinicians and schol-
ars from this tradition tend to view people as inherently prosocial, believing
that personal growth can come from processing one’s emotions and the mean-
ing of experience. When the therapist provides a safe environment in which
clients can explore and express themselves, then growth is inevitable because
of individuals’ drive toward actualization.
In humanistic traditions, people are also seen as self-aware and free to
choose, as well as responsible for the choices they make. Humanistic theo-
rists believe that individuals have the right, desire, and ability to deter-
mine what is best for them and how they will become the best of themselves.
Consequently, humanistic therapists are inclined toward optimizing freedom
and choice within the therapeutic encounter. The humanistic approach
http://dx.doi.org/10.1037/14775-003
S. Rubin (Editors)
49
includes psychotherapies known as client- or person centered, emotion focused
(also known as process–experiential), Gestalt, existential, focusing oriented, rela-
tional, experiential, and narrative, to name the most prominent.
In this chapter, we provide a very brief summary of research conducted
up to 2000 (covered in the first edition of this book). Research since then is
reviewed in more detail, particularly meta-analytic reviews of outcome studies
that describe the impact of treatment (a) over the course of therapy, (b) com-
pared with no treatment, (c) compared with placebo and related controls, and
(d) contrasted with therapies derived from other theoretical systems. In addi-
tion, when research from other orientations bears directly on the outcomes
and processes of humanistic psychotherapy, we note it as well. This review is
followed by an examination of studies (process research) that have explored
in-session attitudes and behaviors (moment-to-moment therapist activities)
and either their consequences for moment-to-moment client responses or the
summed effects of such activities on client well-being. The goal is to summa-
rize findings and translate them into practice and training. At the end of the
chapter, we place special emphasis on innovations for increasing the effective-
ness of humanistic psychotherapy.
SUMMARY OF MAJOR RESEARCH UP TO 2000
By 2000, the humanistic therapies—in particular, person-centered

psychotherapy—were firmly established as effective treatments for a variety
of disorders. In addition, training and supervision methods had been firmly
established and tested by rigorous research designs. Beginning in the 1940s
and early 1950s, Rogers and his colleagues (e.g., Rogers & Dymond, 1954)
conducted uncontrolled studies of the processes and outcomes of client-
centered therapy. Other related humanistic traditions such as existential and
Gestalt therapy did not follow suit until recent decades, but the evidence for
their effectiveness has slowly been accumulating.
By the time the first edition of the classic research compendium Handbook
of Psychotherapy and Behavior Change (Bergin & Garfield, 1971) was published,
person-centered research was represented by Truax and Mitchell (1971), who
focused on certain therapist interpersonal skills, although other chapters in
the text also looked at humanistic treatments such as experiential group ther-
apy. These chapters examined research through the end of the 1960s, with a
rich set of findings that established not only the success of person-centered
treatments but also the importance of the hypothesized change mechanisms,
particularly accurate empathy, its relationship to change, and its effect on
the client process variable of experiencing (depth of self-exploration). Just as
important, the research presented showed that the person-centered attitudes
50 lambert, fidalgo, and greaves

of empathy, unconditional positive regard, and congruence could be reli-
ably specified and operationalized for research purposes and then measured.
Empathy could be taught and learned in a relatively short period of time, as a
therapist skill. However, other attitudes (e.g., respect, unconditional regard,
genuineness) emphasized by person-centered theory proved more difficult to
teach, although they could be enhanced by training programs through the use
of personal growth groups and appropriate supervision.
In the second edition of the Handbook of Psychotherapy and Behavior
Change, Garfield and Bergin (1978) did not devote a separate chapter to
humanistic treatments. A lull in research on humanistic therapies was evi-
dent by the 1980s, in part because of the success of behavioral and cogni-
tive therapies that had strong research traditions. In the 1986 handbook
(Garfield & Bergin, 1986), the place of specific humanistic therapies was
even less obvious, with the exception of a chapter on experiential group
therapy (Kaul & Bednar, 1986) and continuing attention to therapist empa-
thy and related humanistic constructs in many of the chapters (e.g., Orlinsky
& Howard, 1986).
By 2000, economic pressure on mental health services (in North America
and around the globe), scientific and political forces, and reimbursement sys
tems all moved in the direction of offering standardized (manual-guided), time-
limited psychotherapy for specific disorders for which there was clear empirical
support (Task Force on Promotion and Dissemination of Psychological Pro
cedures, 1995). Understandably, by 2000 humanistic therapists were alarmed at
the undervaluation of their work (e.g., Schneider, 1998). Even so, by the time of
the fourth edition of the Handbook of Psychotherapy and Behavior Change (Bergin
& Garfield, 1994), a chapter was finally devoted to the effects of person-centered
and experiential psychotherapies (Greenberg, Elliott, & Lietaer, 1994), which
summarized research through the 1980s. At that time, Greenberg et al. (1994)
were able to locate 37 studies of a variety of humanistic treatments, finding
that change from pretreatment functioning to posttreatment functioning was
characterized by an effect size of d = 1.37, an outcome that is considered large
by Cohen’s criterion. The effects were generally lasting, with clients on aver-
age maintaining their gains for at least a year or longer. If one were to contrast
the overall effect of experiential treatments with effects achieved through rou-
tine medical interventions (such as aspirin or anticholesterol medications to
prevent heart attack, for which d = 0.12), the impact of experiential therapies
would be seen to be substantial and even remarkable (Leucht, Hierl, Kissling,
Dold, & Davis, 2012).
A more rigorous estimate of the effects of studied experiential psycho-
therapies in comparison with various control groups (attempting to control
for the passage of time) reduced the number of studies available (N = 15) but
allowed for an estimate of how much better off (if at all) clients were than
effective humanistic psychotherapy processes 51

control clients who went untreated (Greenberg et al., 1994). In controlled
investigations, Greenberg et al. (1994) found an effect size of 1.30 across vari-
ous outcome measures—again a large effect and one that allows us to estimate
that engaging in experiential psychotherapy would produce an improvement
rate of at least 80% in treated individuals compared with 20% improvement
in untreated controls.
In this review, Greenberg et al. (1994) found 27 studies comparing
experiential therapies with other forms of psychotherapy. They reported that,
although there was great variability from one study to the next, the treat-
ments were, on average, not very different, although the small number of
comparisons between specific types of treatment could partially have led to
the equivalence conclusion.
Throughout this chapter, effect size is discussed, usually in relation to
the d statistic, which expresses difference or change as standard deviation
units. Say, for example, that depressive symptomatology was being measured,
and the average at intake for treated individuals was at the 50th percentile.
If d were 1.0, the average treated individual improved enough to be at the
16th percentile. Likewise, a d of 2.0 indicates that the average treated person
has improved by 2 standard deviation units and can now be found at the
second percentile (instead of the 50th percentile of client samples). A d of
1.37, as in the findings just reported, suggests that the average person treated
with a humanistic therapy moved 1.33 standard deviation units or to the
8th percentile. Later in the chapter, d is used to express the difference between
a humanistic therapy and a contrasting group at posttreatment. A d in this
instance shows how much difference there is between two treated groups at the
end of treatment. These effect sizes are typically around zero if the contrast
group is in active treatment and larger if the contrast group is a no-treatment
(wait-list) control.
Greenberg et al.’s 1994 review was followed by one in 2004 (Elliott,
Greenberg, & Lietaer, 2004; see also Sachse & Elliott, 2002) that can be
used to summarize the state of knowledge as of 2000. Elliott, Greenberg, and
Lietaer (2004) found triple the number of studies that examined pre- to post-
treatment change in treated individuals (N = 112 studies and 127 treatment
groups), with the effect size remaining large (d = 0.99). Long-term follow-up
indicated that treated individuals maintained their gains or experienced
further improvement, whereas untreated individuals did not improve. The
number of available studies that contrasted humanistic therapies with no-
treatment or wait-list controls rose to 45, with an effect size of d = 0.89,
nearly identical to the pre- and posttreatment findings. Elliott, Greenberg,
and Lietaer (2004) also found 74 comparisons between humanistic psycho-
therapy and other forms of treatment, indicating that the differences between

treatments were, on average, nonexistent (d = 0.04) but varied considerably
depending on a variety of factors. Indeed, the variation was so great that,
on occasion, the humanistic therapy surpassed the contrasting treatment,
with the reverse occurring just about as frequently. Some comparisons were
made between different forms of humanistic psychotherapies, with emotion-
focused therapy surpassing person-centered treatment.
It can be said that by 2000 there had been somewhat of a renaissance
in the study of humanistic psychotherapy outcomes. Although new inter-
est in these treatment effects was obvious, research on cognitive–behavioral
therapy (CBT) in its various forms increased exponentially, so that evidence
for the effects of humanistic psychotherapy with specific disorders was, in
contrast, relatively sparse. Nevertheless, it was abundantly clear by 2000 that
clients with a variety of disorders achieved significant benefit from entering
the experiential psychotherapies that had been studied; moreover, clients
were much better off than those who were suffering but did not enter treat-
ment, although little evidence could be found that humanistic treatments
were uniquely effective among the wide variety of psychotherapies that had
been studied (e.g., psychodynamic, CBT).
WHAT THE CURRENT RESEARCH (2000–PRESENT)

TELLS US ABOUT EFFECTIVE PRACTICE
In the most recent edition of the Handbook of Psychotherapy and Behavior

Change (Lambert, 2013a), Elliott, Greenberg, Watson, Timulak, and Freire
(2013) again summarized published studies on the effectiveness of humanistic–
experiential psychotherapies through the use of quantitative (meta-analytic)
review methods. The body of available evidence continued to grow, although
the evidence base continued to be small relative to more highly structured
treatments such as various CBTs. Elliott et al. (2013) were able to draw on
nearly 200 humanistic and experiential psychotherapy studies, covering pub-
lished research from 2001 to 2008, and on overlooked studies found since their
earlier Handbook reviews. Their meta-analysis again addressed the question
of the effectiveness of these therapies compared with no-treatment condi-
tions, but it also looked at them in relation to other treatments. Recognizing
that the future viability of humanistic treatments may rest on the degree to
which such treatments are evidence based, they applied the scientific criteria
for effectiveness drawn from Chambless and Hollon (1998). These criteria
rate the degree to which psychotherapies (and other practices) are empiri-
cally supported by classifying the evidence with regard to the level of empirical
support. To be considered, studies have to meet quality standards (e.g., large

sample size, proof of treatment fidelity, recognizable specific disorder, reliable
outcome measures).
The level of evidence ranged from possibly efficacious—at least one con-
trolled study in support of a treatment without any contradictory evidence—
to efficacious—the treatment was either superior to a no-treatment control
group or equivalent to an established treatment, in at least two independent
research settings and based on a preponderance of evidence. For a treatment
to be efficacious and specific required that it be found superior to a treat-
ment that is bona fide, meaning given by a trained therapist and based on
research evidence in at least two independent research settings. In the case
of conflicting evidence, the treatment must be supported by a preponderance
of well-controlled studies. To promote and enhance an effective practice of
psychology, the American Psychological Association (APA) Presidential
Task Force on Evidence-Based Practice (2006) broadly defined the evidence-
based practice of psychology as the “integration of the best available research
with clinical expertise in the context of client characteristics, culture, and
preferences” (p. 275). According to the APA task force, clinical expertise refers
to psychologists’ competence to conduct effective practice by applying skills
gained through education, training, and experience. Evidence-based practice is a
broader term than evidence-based treatment. For a specific treatment to be evi-
dence based, Elliott et al. (2013) relied on the Chambless and Hollon (1998)
criteria presented earlier.
To determine whether humanistic psychotherapies were effective when
considering pretreatment–posttreatment change (which is not considered in
the criteria for evidence-based treatment), Elliott et al. (2013) analyzed the
pre–post effects size data from about 199 samples of clients (a total of 14,206
clients), 77 of which were not reported in their prior review (Elliott, Greenberg,
& Lietaer, 2004). These clients were seen in different subtypes of humanistic
psychotherapies, with a majority of studies (n = 74) examining person-centered
treatment, 33 studies focusing on generic versions of person-centered psycho
therapy (usually labeled nondirective or supportive), and a similar number (n = 34)
focusing on integrative task-focused variations, that is, process–experiential
therapy (also referred to as emotion-focused therapy), which included individual,
couple, and group treatments.
Elliott et al.’s (2013) review did not include organized integrative therapies
such as third-wave cognitive–behavioral psychotherapies such as acceptance
and commitment therapy (Hayes, Strosahl, & Wilson, 1999), mindfulness
therapies (Segal, Williams, & Teasdale, 2001), compassionate mind therapy
(Gilbert, 2009), or emotion-focused psychodynamic combinations (e.g., Fosha,
2000), which rely heavily on humanistic principles and could arguably be
included. Of particular interest to humanistic therapists, the available evidence
did allow Elliott et al. to consider differences in outcome between therapies

that were higher and lower in directiveness or process-guiding activities
within the humanistic tradition.
Elliott et al.’s (2013) analysis demonstrated that, when looking across
the treatment samples and the assessment periods, the pretreatment to
posttreatment effect size was significant and large (d = 0.96), suggesting that
the change experienced during psychotherapy moved the average client
from the 85th percentile of psychological disturbance to the 50th percentile.
These results were consistent with, although slightly lower than, their pre-
2000 findings. This large effect size was maintained or increased at follow-
up—allowing for the conclusion that the clients maintained and, in some
cases, even increased their treatment gains during the period after closure of
therapy (Elliott et al., 2013). A majority of clients who enter the humanistic
therapies (that have been studied) improve and maintain gains 12 or more
months after treatment on the wide variety of standardized measures used to
operationalize mental health functioning (Ogles, 2013).
These studied treatments provided, on average, 20 sessions of therapy
(with very large differences in dosage across studies). About 60% of research-
ers who designed studies had an allegiance to the humanistic approaches.
Obviously, clients who undergo treatment in these research studies experi-
ence substantial reductions in the subjective pain that mental health prob-
lems cause, but pre–post change does not allow us to conclude that they
would not get the same degree of change from participation in other psycho-
therapies, the passage of time, or even self-help interventions that are widely
available through a variety of media.
Comparisons With No-Treatment and Wait-List Controls
More rigorous studies (studies with a control group) that attempted to

rule out the effects of time by means of simultaneous study of clients who
were denied treatment, received presumably inferior or bogus treatment, or
were placed on a wait list, included a sizable number (n = 62) of comparisons.
Elliott et al. (2013) found that the controlled effect size for these studies was
large (d = 0.81), with the average pre–post effect size for the experiential cli-
ent (d = 1.01) substantially larger than that found for the untreated individu-
als (d = 0.19) who also experienced some benefit. These results, based on a
large number of studies, leave little doubt that humanistic–experiential inter-
ventions create more benefit than can be achieved by clients who forgo or
delay psychotherapy. It is also important to note that the effects of treatment
were found to be lasting. This finding implies that the therapies studied do
not just provide temporary relief from psychological disturbance but provide
change in ways that are more in line with personality change, actualization,
or the acquisition of coping skills.

Effects of Humanistic Psychotherapy Compared
With Alternative Treatments
Elliott et al. (2013) were able to locate 135 treatment comparisons based
on studies examining humanistic–experiential therapies compared with a vari-
ety of other treatments, usually in the context of helping clients manifesting
a primary diagnostic class or disorder. This analysis indicated mixed effects
in comparative treatment studies, with considerable variability. When consid-
ered as a whole, they found no overall difference between treatments in the
135 studies (d = -0.02). In this analysis, 60% of the studies showed that the
treatments (humanistic vs. nonhumanistic) were equivalent, and 21% of
the studies favored the nonhumanistic therapy and 19% favored the human-
istic treatment over the nonhumanistic one. Elliott et al. suggested that such
widely inconsistent findings can be explained, to a large degree, by researcher
allegiance effects, a construct operationalized by Luborsky et al. (1999), who
found that many studies comparing treatments were not conducted by research-
ers who equally included representatives of the two competing therapies—that
is, researchers were not equally invested in both treatments. This has been a
problem especially in comparison studies that use a treatment-as-usual con-
trol group (Wampold et al., 2010) and has led to the suggestion that such
groups, rather than being called treatment as usual, should be labeled intention
to fail controls because the groups are often offering very poor treatment rather
than a reasonable alternative therapy. When Elliott et al. controlled for the
effects of researchers’ allegiance and bias on effect size, the results demonstrated
that humanistic therapies are clinically and statistically equivalent to other
treatments.
Given the widespread belief, especially within academic departments
in the United States, that CBT is a uniquely effective treatment, compar-
ing treatment outcomes between CBT and humanistic treatments seems
especially interesting to humanistic theorists and practitioners. Elliott et al.
(2013) found a surprising large (n = 76) number of studies that compared
humanistic and CBT treatments (allowing for the fact that many types of
both CBT and humanistic therapy exist). These included studies of differ-
ent types of CBT and experiential therapy and many different client popu-
lations. Overall, the weighted effect size was d = -0.13, which was small
and favored CBT. When only the subset of studies that reported randomized
controlled trials (the most rigorous designs) was considered, the number of
studies shrank to 65 and produced an effect size of -0.14, with both results
favoring CBT.
At face value, effect sizes of this kind suggest that the relative success
rate of CBT-treated clients would be about 54%, and the rate for humanisti-
cally treated clients would be 46%. Over long periods of time, if large client

populations are considered, such a difference would have important practical
implications. However, when the small advantage for CBT treatments was
adjusted for researcher allegiance effects, that advantage disappeared. The
correlation between allegiance and outcome in this set of studies was .49,
showing a considerable bias against experiential treatments. The effect size
difference within randomized controlled trials comparing CBT and experien-
tial therapies dropped to a -0.02. This little-known fact has not yet reached
academic departments, policymakers, or the public at large.
Although it can generally be said that no differences in the outcome
of clients who underwent the compared treatments was found, some find-
ings suggested that outcomes differed by diagnosis. Conclusions with regard
to diagnosis have certain presumed advantages for delivery of care, such as
selecting the best treatment for a disorder, making referrals to other provid-
ers who offer more efficacious treatment, and improving quality control for
administrators and policymakers who fund service delivery. Putting aside the
many problems associated with evidence-based treatments (such as the fact
that there are hundreds of disorders and theory-based treatments), it can be
noted that it is impossible for clinicians to learn more than a few specific
treatments. In addition, the majority of clients in most settings present with
more than one type of problem. Nevertheless, there may be valid arguments
for matching specific treatments to specific clients or client problems when
research evidence exists for doing so.
Comparisons and equivalence analysis on depression have shown that
humanistic psychotherapies are efficacious treatments, based on large pre-
treatment to posttreatment changes, their superiority over no-treatment
controls, and their general equivalence to other treatments such as CBT.
For instance, comparisons of humanistic and nonhumanistic psychotherapies
have suggested that these treatments had equivalent effectiveness for treat-
ment of depression. Humanistically and nonhumanistically treated clients
had large improvements from the beginning to the end of treatment (i.e.,
pre–post effect size was large; d = 1.23). At this writing, APA Division 29’s list
of evidence-based treatments includes 13 distinct treatments for depression
with a judged evidence base that ranges from strong to moderate (see http://
www.div12.org/psychological-treatments/disorders/depression). Emotion-
focused therapy is one of the 13 treatments, with its rating being modest
evidence. Lists of treatments will undoubtedly expand over time. Regardless
of these lists, and based on the meta-analytic evidence summarized here, it
seems unnecessary for a therapist practicing humanistic psychotherapy (espe-
cially those who practice emotion-focused therapy) to refer out clients with
depression. Policymakers can consider a wide range of treatments for indi-
viduals who present with primary depressive symptoms, including a variety
of humanistic treatments.

In contrast, the research literature has suggested that humanistic treat-
ments are less effective with some anxiety-based problems than the behavior
and cognitive–behavioral therapies with which they have been compared.
This appears to be especially clear for clients with generalized anxiety dis-
order, agoraphobia, and panic. The average effect size difference favoring
CBT was d = -0.39, with none of the individual studies favoring humanistic
treatments. A difference of this size suggests that the success rate for CBT
clients would approximate 60%, whereas that for clients receiving human-
istic therapy would approximate 40% (Elliott et al., 2013). Unfortunately,
the most commonly compared humanistic therapies have been supportive
or nondirective control therapies, which are often intention-to-fail controls
rather than emotion-focused or person-centered treatments. This may have
exaggerated the differences between humanistic treatments and CBT. The
advantage for CBT treatments is further diminished when researcher alle-
giance is factored in (d = -0.18, favoring CBT), but a small advantage for
CBT remains.
Speculation about the reasons for CBT’s slight superiority encompasses
two related possibilities. The first is the importance of psychoeducation about
the role of autonomic nervous system arousal in anxiety disorders (especially
panic). The second is that anxious individuals seek, and may be comforted by,
more highly structured approaches. The implications for treatment are clear
for the humanistic approaches, which must consider providing clients with
panic and generalized anxiety disorders with an explanation of their distress-
ing experience that includes presumed automatic physiological responses,
as well as offering ways to cope with these reflexive responses, such as relax-
ation and breathing or mindfulness techniques. Clearly, anxiety-impaired
clients benefit from experiential psychotherapies, which are possibly effica-
cious, according to Chambless and Hollon’s (1998) criteria, but it appears
that testing the effects of modified experiential treatments could pay strong
dividends. It is fair to say that the field has already moved toward integrative
treatments in routine care, in which therapists have the freedom to blend
techniques, as opposed to clinical trials in which therapists are expected to
adhere to the monotherapies that are the subject of study.
In contrast to findings with some anxiety disorders, the humanistic treat-
ment of relationship problems indicates an advantage of experiential treat-
ments over CBT and other therapies. Relationship problems treated by
humanistic methods have dealt mainly with unresolved relationship issues
related to infidelity and abuse or more general interpersonal problems. Across
24 studies that examined relationship issues, most used emotion-focused
couples therapy, but a significant number also considered resolution of emo-
tional injuries and traumatic events (but not posttraumatic stress disorder
per se) treated in couples or individual therapy. The effect size of change

from pretreatment to posttreatment was large (d = 1.23), but with large vari-
ability. Comparisons with control groups remained large in the subset of studies
that used them (d = 1.39), with all studies showing a positive effect and
all being superior to improvements in wait-list clients. In comparison with
other treatments (mainly CBT), the humanistic treatments appeared supe-
rior (d = 0.34), enough so to conclude that they can be advocated (Elliott
et al., 2013).
It should be kept in mind that the Elliott et al. (2013) review did not
examine the family or couples therapy literature generally. Nor did it investi-
gate the superiority of emotion-focused couples therapy vis-à-vis other couples
therapy approaches, particularly with regard to improving couple distress. It is
not obvious from the literature on many types of couples treatment (Sexton,
Datchi, Evans, LaFollette, & Wright, 2013) that emotion-focused couples
treatment stands alone as effective. In the area of couple distress, however,
emotion-focused couples therapy has long been recognized as efficacious (e.g.,
Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). More important, within
the humanistic family of treatments, emotion-focused (couples) therapy
was consistently found to be more effective than person-centered treatment
(Elliott et al., 2013), with the greater degree of process-directive activities
accounting for the difference. The emotion-focused therapies may also be more
centered on the relationship problems that are presented than on the growth
of individuals.
In the more general case, not all humanistic therapies have the same level
of process-guiding activities. Indeed, the idea of process guiding seems to exist
on a continuum with different intensities. For instance, person-centered ther-
apy or supportive therapies are less process guiding than emotion-focused ther-
apy. Elliott et al. (2013) compared and analyzed the effectiveness of humanistic
therapies differing in level of process guiding. They gathered nine comparisons
from different studies, finding that the humanistic therapies low on process
guiding were clinically less effective than CBT. However, high process-guiding
humanistic therapies were equivalent to CBT for the total sample of compara-
tive studies (Elliott et al., 2013).
SUMMARY
This brief recap of humanistic outcome research, based largely on the

recent meta-analytic review of Elliott et al. (2013), has many implications for
practice, training, and policy. First and foremost, it is inappropriate for acade-
micians and policymakers to consider these treatments ineffective or inferior.
Clients who participate in these psychological therapies make gains from the
beginning to the end of treatment that are quite similar in effectiveness to

those of clients participating in other treatments. These gains, achieved in
20 or fewer sessions, are maintained after termination. Studies that control
for the passage of time (e.g., using wait-list controls) have also shown large
to moderate treatment effects favoring humanistic therapies. In comparison
studies, the usual finding is that no or small differences can be found in client
outcome between treatments. In these studies, multiple symptom scales as well
as measures of life functioning have been used to quantify outcome rather than
more humanistic theory-specific measures. It remains to be seen whether either
type of measure indicates that the effects of treatment are larger, particularly if
humanistic-specific measures produce larger treatment effects for humanistic
psychotherapies.
Because about two thirds of clients participating in randomized controlled
trials find a reliable benefit from psychological treatments (including human-
istic treatments; Hansen, Lambert, & Forman, 2002), it is important to rec-
ognize that a substantial minority of clients come and go from treatment
(including humanistically oriented therapy) without responding. We return to
this problem near the end of the chapter. Before doing so, we consider empiri-
cal literature on the factors that promote change in humanistic and other
therapies.
OTHER RESEARCH SUPPORT RELEVANT

TO HUMANISTIC TREATMENTS
Much of the research that has attempted to estimate the effects of psycho
therapy on clients is relevant to humanistic treatments, even though it was
not designed to test their effects as such. Efforts to promulgate evidence-based
psychotherapies have been noble in intent and are praiseworthy efforts to
distill scientific research into clinical applications and to guide practice and
training. Research results have demonstrated that, in a climate of account-
ability, psychotherapy stands up to empirical scrutiny with the best of health
care interventions. At the same time, many practitioners and researchers
have found efforts to codify evidence-based treatments seriously incomplete.
Although scientifically laudable in their intent, these efforts have largely
ignored the therapy relationship, the person of the therapist, and the con-
tribution of clients (outside of diagnosis). If one were to read previous efforts
literally, they suggest that disembodied therapists apply manualized interven-
tions to discrete Diagnostic and Statistical Manual of Mental Disorders disorders.
Not only is that language offensive to some practitioners on clinical grounds,
but the research evidence is weak for validating treatment methods in isola-
tion from the therapy relationship and the individual client.

This research stands in marked contrast to the clinician’s (and client’s)
experience of psychotherapy as an intensely interpersonal and deeply emo-
tional experience. For example, although efficacy research has gone to consid-
erable lengths to eliminate the individual therapist as a variable that might
account for client improvement, the inescapable fact of the matter is that it
is simply not possible to mask the personal qualities and contribution of the
therapist as a person as well as the nature of the client–therapist relationship.
The beneficial contribution of the person of the therapist is, arguably, more
empirically validated than manualized treatments or psychotherapy methods
per se (Baldwin & Imel, 2013).
Two controlled studies examining therapist variables in the outcomes
of CBT are instructive (Huppert et al., 2001; Project MATCH Research
Group, 1998). In the Multicenter Collaborative Study for the Treatment of
Panic Disorder, considerable care was taken to standardize the treatment, the
therapist, and the clients to increase the experimental rigor of the study and
to minimize therapist effects. The treatment was manualized and structured,
the therapists were identically trained and monitored for adherence, and the
clients were rigorously evaluated and relatively uniform in their diagnosis.
Nonetheless, the therapists significantly differed in the magnitude of change
among caseloads: Effect sizes for therapist impact on outcome measures
ranged from 0% to 18%. In the similarly controlled multisite study on alcohol
abuse conducted by Project MATCH, the therapists were carefully selected,
trained, supervised, and monitored in their respective treatment approaches.
Although few outcome differences among the treatments were found, more
than 6% of the outcome variance (range = 1%–12%) was due to therapists.
Despite impressive attempts to render individual practitioners experimen-
tally as controlled variables, it is simply not possible to mask the person and
the contribution of the therapist.
Both clinical experience and research findings have underscored that the
therapy relationship accounts for as much or more of the outcome variance as
particular treatment methods. Meta-analyses of comparative psychotherapy
outcome literature have consistently revealed that specific techniques account
for 0% to 5% of the outcome variance (e.g., Lambert, 2013b; Wampold, 2001).
An early and influential review by Bergin and Lambert (1978) anticipated the
contemporary research consensus:
The largest variation in therapy outcome is accounted for by pre-existing
client factors, such as motivation for change, and the like. Therapist per-
sonal factors account for the second largest proportion of change, with
technique variables coming in a distant third. (p. 180)
Even those practice guidelines enjoining practitioners to attend to the
therapy relationship have not provided specific evidence-based means of doing

so. The APA (Task Force on Promotion and Dissemination of Psychological
Procedures, 1995), for example, sagely recognized that factors common to all
therapies, “such as the clinician’s ability to form a therapeutic alliance or to
generate a mutual framework for change, are powerful determinants of suc-
cess across interventions” (pp. 5–6) but only vaguely addressed how research
protocols or individual practitioners should do so. For another example, the
scholarly and comprehensive review of treatment choice from Great Britain
(Department of Health, 2001) devoted a single paragraph to the therapeutic
relationship. Its recommended principle was “[the] effectiveness of all types of
therapy depends on the client and the therapist forming a good working rela-
tionship” (p. 35), but it offered no evidence-based guidance on which thera-
pist behaviors contribute to or cultivate that relationship. Likewise, although
most treatment manuals mention the importance of the therapy relationship,
few specify what therapist qualities or in-session behaviors lead to an optimal
relationship. In contrast, Elliott, Watson, Goldman, and Greenberg (2004)
provided evidence of the importance of specific tasks and activities for devel-
oping the alliance as it relates to stages of therapy and special therapeutic
situations.
All of this is to say that extant lists of evidence-based treatments and
best practices in mental health give short shrift—some would say mere lip
service—to the person of the therapist and the emergent therapeutic rela-
tionship. The vast majority of current analyses are thus seriously incomplete
and potentially misleading, on both clinical and empirical grounds. In recog-
nition of this fact, APA Divisions 29 and 12 (Society for the Advancement
of Psychotherapy and Society of Clinical Psychology) commissioned a task
force to identify, operationalize, and disseminate information on empirically
supported therapy relationships, in the hopes of balancing the importance
of relationship with that of treatments already existing in the field. Norcross
(2011), who headed up this task force, provided a summary of its work, includ-
ing implications for practice. Norcross and Lambert (2011) suggested that
the impact of treatment methods is inextricably bound to the relationship
context in which they are applied, arguing that an overview of the empiri-
cal literature supports the conclusion that the largest portion of variance
not attributable to preexisting client characteristics involves (a) individual
therapist differences and (b) the emergent therapeutic relationship between
client and therapist, regardless of technique or school of therapy. Therefore,
the task force members attempted to expand and enlarge the typical focus
on evidence-based treatments to include therapy relationships. Of necessity,
the task force had to determine which relational behaviors to include in and
exclude from the review (a difficult task), but settled on the Rogerian facilita-
tive conditions, the therapeutic alliance (in individual psychotherapy), and
cohesion (in group psychotherapy) as core elements. Other constructs were

chosen (or eliminated) because of the availability or lack of research evi-
dence. Each author was asked to provide a meta-analysis of the studies he
or she reviewed, estimating the percentage of variance each accounted for
in predicting client change, as well as providing bulleted implications for
practice. Finally, a panel was engaged to rate each of the relational elements
with regard to the strength of the evidence base—demonstrably effective,
probably effective, or promising but insufficient research to judge.
Considerable variability was found in the ways in which constructs were
operationalized for research purposes, with the ratings made by clients, thera-
pists, and trained judges. Within constructs, many different scales were used.
For example, Horvath, Del Re, Flückiger, and Symonds (2011) indicated that
there is no agreed-on definition of the therapeutic alliance, with no fewer
than 30 different scales being used in the 201 studies they examined in their
meta-analysis of its effects. Remarkable consistency was found in estimates
of the correlation between the relationship variables and outcomes across
populations (e.g., individual, child, family, group therapy) and constructs
(e.g., empathy, therapeutic alliance, collaboration, positive regard, cohesion).
It is reasonable to conclude that the relationship between the core elements
emphasized by humanistic therapy approaches and client improvement is
rather consistent and that, on average, the correlation is about .25 to .30.
This correlation translates to an effect size (d) of about 0.55, suggesting that
clients receiving psychotherapy characterized by high degrees of empathy,
genuineness, and so forth will have an advantage over clients receiving rela-
tively lower degrees of these relationship attitudes. Although this estimate of
treatment effects may seem small, the reader should keep in mind that many
complex variables contribute to client improvement, especially attitudes and
characteristics that the client brings to the therapeutic encounter along with
life events.
It is obvious from the meta-analytic data that the correlational evi-
dence provided across reviews that isolated the relationship variables cannot
be assumed to be independent; moreover, the amount of variance accounted
for by each construct cannot be added or summed to estimate an overall
contribution of the relationship variables that exceeds the .30 estimate. For
example, Watson and Geller (2005) found the correlation between the client-
centered conditions and the therapeutic alliance to be .72. Many studies in
the Horvath et al. (2011) meta-analysis also showed up in the meta-analysis
of collaboration (Tryon & Winograd, 2011), perhaps because a therapeu-
tic alliance measure or subscale was used to operationalize collaboration.
Unfortunately, the degree of overlap among all the measures (and, therefore,
constructs of relationship variables) is not available, although it is bound to
be substantial. In an early research review on the client-centered conditions
using (mainly) the Barrett-Lennard Relationship Inventory, Gurman (1977)

found empathy correlated .53 with positive regard, .62 with congruence,
and .28 with unconditionality. Factor-analytic studies of the Barrett-Lennard
Relationship Inventory have suggested that it produces a single global factor,
with empathy, positive regard, and congruence all loading highly (e.g., Blatt,
Sanislow, Zuroff, & Pilkonis, 1996).
The concept of positive regard may be difficult to tease apart in research,
because it is so closely linked to empathy and genuineness. Measures such as
the Truax Relationship Questionnaire (Truax & Carkhuff, 1967) and the
Barrett-Lennard Relationship Inventory (Barrett-Lennard, 1964, 1978) are
most commonly used to find the effect that positive regard has on therapeutic
change. Interestingly, some of the items on these measures are coded for more
than one construct. In the Relationship Questionnaire designed by Truax
and Carkhuff (1967), for example, a client’s response to one specific item may
increase the score on both scales of positive regard and genuineness, reflect-
ing the interaction between them (e.g., “He seems to like me no matter what
I say to him”; Farber & Doolin, 2011, p. 172). As Kolden, Klein, Wang, and
Austin (2011) argued, therapist congruence is absolutely necessary for thera-
peutic change, because “neither empathy nor regard can be conveyed unless
the therapist is perceived as genuine” (p. 187). Again we can see that positive
regard, empathy, and congruence are intricately interwoven.
In addition to the general outcomes of humanistically oriented psycho-
therapy and the correlational evidence from the quantitative analysis of pro-
cess variables on humanistic and other psychotherapies, a growing number
of qualitative and case studies have shed light on psychotherapy processes
and client outcomes. The findings are based on intensive postsession or post-
therapy interviews of client-perceived change and associated processes using
qualitative methods. Enough evidence has accumulated in recent years that
an integrative review of the evidence was published by Timulak and Creaner
(2010), who found that responses could be divided into 11 categories of client
change. In general, clients described becoming more aware of and accepting
of self, increasing self-compassion, being more open to both pleasure and pain,
and experiencing themselves as stronger and more able to tolerate their own
vulnerabilities. The general findings using qualitative methods are highly con-
sistent with humanistic theories of change. As suggested by theory, the people
who were studied not only came to like themselves more but experienced
greater liking and acceptance of others. Changes were often attributed to the
relationship they had with their therapist and, in particular, to the empathic
and compassionate presence of the therapist. Clients described experiencing
a sense of connectedness with their therapist that promoted awareness and
trust of self.
In case studies, good-outcome clients felt more supported by their thera-
pist, which enabled them to explore difficult experiences and feelings that

they had avoided in the past (e.g., Brinegar, Salvi, & Stiles, 2008). Elliott et al.
(2013) summarized case study research by suggesting that
change comes via (a) the therapist responding to the client’s core hurt/
pain; (b) mobilization of the client’s previously obscured unmet needs
(typically to be respected, close, or secure); (c) the therapist offering
compassion and affirmation to those unmet needs as well as the client’s
self-compassion or protective anger/determination. (p. 514)
PROCESSES UNIQUELY EFFECTIVE WITHIN HUMANISTIC

TREATMENTS BEYOND CLIENT-CENTERED CONDITIONS
Emerging research evidence that contrasts two forms of humanistic

treatment has challenged basic tenets of person-centered theorists by ask-
ing therapists to be more active in providing process guidance for clients.
Historically, the contrast has been between the presence of attitudes specified
by Rogers (1957) and client experiencing through process-guided focusing
as delineated by Gendlin (1996). More recently, this area of study has had a
greater focus on techniques and interventions that go further in directing the
process of therapy. Emotion-focused therapy theorists and researchers believe
that therapy can be more marker driven; thus, therapists who make use of
markers to employ certain techniques will facilitate greater improvement in
clients. Central among the process-guided approaches previously mentioned
are those advocated by Greenberg et al. (1994; e.g., “Learning Emotion-Focused
Therapy: The Process-Experiential Approach to Change”; Elliott, Watson, et al.,
2004). Critical techniques are the empty-chair method, which is prompted by
a marker indicating unfinished interpersonal business, and the two-chair tech-
nique for resolving internal conflict. One motivation behind greater emphasis
on these techniques is their ability to heighten access to emotion and the
corresponding belief that problematic emotions can be changed by other emo-
tions. But, of course, emotion-focused therapy and focusing approaches always
advocate “relationship first” before process guidance.
Research in this area is adding knowledge to our understanding of
the complexity of change. For example, Shahar et al. (2011) found that the
two-chair dialogue in self-critical individuals facilitated self-compassion and
self-supportive inner dialogue and reduction of self-criticism, anxiety, and
depressive symptoms. Greenberg and Foerster (1996) found greater resolu-
tion of unfinished business using empty-chair work compared with empathy
alone. Paivio, Jarry, Chagigiorgis, Hall, and Ralston (2010) reported simi-
lar findings with trauma work. In general, the process work in this area has
shown that greater emotional arousal is associated with these methods, that

this arousal is most helpful when clients have the hardest time accessing their
emotions, and that the methods may not be helpful when arousal is already
at a very high level.
A RESEARCH-BASED METHOD FOR IMPROVING OUTCOMES

IN HUMANISTIC PSYCHOTHERAPIES: ROUTINE MONITORING
WITH ALARM SIGNALS AND PROBLEM-SOLVING TOOLS
As noted earlier, humanistic treatments have a powerful effect on client

outcomes, but, as with other therapy approaches, many clients who participate
do not show a measured benefit, and a small portion actually worsen during
treatment. Hansen et al. (2002) examined a representative sample of random-
ized clinical trial outcomes based on 89 treatment comparisons (mostly CBT),
reporting an average of 57% to 67% recovered or improved (using clinically
significant change criteria) after receiving an average of 13 sessions of treat-
ment. These outcomes were contrasted with those found among more than
6,000 clients who participated in routine care that lasted an average of 4 ses-
sions, with clients ranging from those treated in community mental health
centers to those being seen in outpatient clinics. Rates of improvement and
recovery averaged 35%, and deterioration varied from a low of 3.2% to a
high of 14%, with an average rate of 8%. As Hansen et al. pointed out, even
when an empirically supported treatment is offered to individuals who have
the same disorder and see therapists who have been carefully selected, moni-
tored, and supervised, 30% to 50% of clients fail to respond to treatment.
The situation for child and adolescent outcome in routine care is also sober-
ing. In a comparison of children being treated in community mental health
(n = 936) or through managed care (n = 3,075), estimates of deterioration
were 24% and 14%, respectively (Warren, Nelson, Mondragon, Baldwin, &
Burlingame, 2010).
We need to identify clients who are failing to respond to treatment before
they leave our care. Furthermore, increased attention to deterioration in treat-
ment may be warranted, given the high rates of treatment dropout observed in
clinical practice. It is estimated that 40% to 60% of children and adolescents
discontinue treatment prematurely (Kazdin, 1996), and estimates for adults
hover around 20% (Swift & Greenberg, 2012, 2015); many of these drop-
outs are likely because of perceived lack of benefit from treatment, although
a portion indicate satisfaction with a single session and cannot be considered
treatment failures.
Unfortunately, clinicians’ view of their own clients’ outcome is much
more positive. Walfish, McAlister, O’Donnell, and Lambert’s (2012) survey of
clinicians suggested that they estimate improvement or recovery in about 85%

of their clients. In addition, they have the common impression that they,
themselves, are unusually successful, with 90% of therapists rating themselves
in the upper quartile and none seeing themselves as below average in relation
to their peers (whereas 50% are, indeed, below average). With such percep-
tions, clinicians are likely to overlook negative changes. Even when asked
to identify cases that are off track for a positive outcome, clinicians find it
difficult to recognize or predict treatment failures. Hannan et al. (2005) com-
pared clinical trainees, experienced clinicians, and a statistical method’s abil-
ity to predict negative change. Of 550 clients whose progress was evaluated
(of whom 40 deteriorated), only one was accurately predicted to deteriorate
by a trainee, even though therapists were informed that the baseline expec-
tancy for deterioration was 8%. In contrast, the statistical method identified
36 of the 40 deteriorators before the clients left treatment. Of the 20 licensed
professionals who participated in the study, none accurately predicted a single
case of deterioration (as reported by clients). Similar sobering results have
been presented by Hatfield, McCullough, Frantz, and Krieger (2010), who
showed that clinicians seldom (20%–30% of the time) noted client deterio-
ration in treatment by mentioning any worsening in their weekly case notes,
even when the negative change that clients reported on self-report measures
was extreme.
To improve the outcomes of clients who are responding poorly to treat-
ment, such clients must be identified before termination, ideally as early as
possible in the course of treatment. Client worsening can be predicted through
several statistical methods, most of which simply take into account how dis-
turbed clients are at intake and what kind of progress they make over the
course of treatment. To do so, clients’ self-reported level of mental health
functioning needs to be evaluated consistently throughout the course of treat-
ment and compared with expected progress for clients equally at risk on the
basis of their initial level of functioning. Considering clinicians’ tendency and
need to be optimistic about their clients’ future progress, the task of identifying
treatment failure is best left to statistical methods that might profitably be used
even by humanistic clinicians.
In the most recent meta-analytic review of the impact of predicting
treatment failure and providing feedback to psychotherapists, Shimokawa,
Lambert, and Smart (2010) found an effect size for feedback compared with
treatment as usual offered by the same therapists of d = 0.53. These results
suggest that the average at-risk client whose therapist received feedback was
better off than approximately 70% of at-risk clients treated by the same ther-
apists operating without feedback.
Of most relevance to the practice of humanistic therapists was provid-
ing feedback on the therapeutic alliance when the client was identified as a
potential treatment failure. In the context of routine care, clients who are

predicted to have a negative outcome are asked to take a 40-item measure
(Assessment for Signal Cases; Lambert et al., 2007) that includes an Alliance
subscale that is part of a Clinical Support Tool (CST) feedback system. If
clients are predicted to have a poor treatment outcome, therapists are pro-
vided with a report that alerts them if the overall alliance is problematic (1.5
standard deviations below average) and also if there is a problem with the
bond, task agreement, and goal agreement. It also offers specific feedback
on items that are below average relative to other clients (e.g., “My therapist
seems glad to see me”; Lambert et al., 2007). Specific suggestions for repair-
ing a ruptured alliance are drawn from the work on rupture repair reported by
Safran and Muran (2000). The Shimokawa et al. (2010) meta–mega-analysis
suggested that using such techniques further improves psychotherapy out-
comes compared with treatment as usual (d = 0.70). It is important to note
that clinicians probably need to rely on formal assessment of the alliance,
empathy, and so forth to problem solve, because therapists’ judgment of these
relationship variables is not highly correlated with client reports or client
outcome. The use of this feedback system is consistent with humanistic val-
ues and practice and can be considered an example of collaborative empower-
ing because it increases the role of clients as cotherapists or cocreators of the
kind of therapy that works for them. This has a good chance of individualiz-
ing the therapy and making it more egalitarian. Therapist action is prompted
by using cut-off scores based on normative data for other clients rather than
merely by an overall alliance score. This process is illustrated through the
following case material.
This monitoring and feedback approach complements humanistic mod-
els. Most important, it makes clients more active participants in their therapy,
which is predictive of good outcome. Furthermore, it serves to engage and
empower clients, thereby making them collaborative partners with their ther-
apist in cocreating an optimal therapeutic relationship and course of therapy.
FROM RESEARCH TO PRACTICE
Given the evidence for the value of progress feedback and use of CST
feedback, in this section we first highlight a client whose therapist added
these feedback methods to humanistic practice methods. In the second sce-
nario, we illustrate the issue of improving outcomes in clients with anxiety.
In the first case the client’s progress has been monitored from the begin-
ning of psychotherapy through the use of the Outcome Questionnaire—
45 (Lambert et al., 2013). The client, Mary, entered treatment with a score
of 86, which is typical of outpatients and is at the 97th percentile of the
normative population (higher scores indicate more psychological pain). The

client progressed as expected until the fifth session of treatment, at which
time the predictive algorithms gave a red signal, indicating that the client
was predicted to leave treatment worse off than when starting (for clients
who began at her level of distress, 90% showed greater progress at the fifth
session). Mary was asked whether she would be willing to respond to a ques-
tionnaire (the CST measure of alliance, motivation, social supports, and neg-
ative life events) at this time and then discuss her answers with the therapist.
The following dialogue ensued after the therapist had reviewed the progress
feedback and CST reports.
Session 5:
Therapist: Mary, before we begin today, I wanted to review with you
your recent score on the measure you take before each ses-
sion. Here is a graph of your scores since you came into the
clinic. This blue line indicates how you’ve rated your mental
health functioning before each session we have had. This
black line indicates the responses of a nationwide sample of
clients who started therapy with the same degree of initial
discomfort that you reported when you came. Here is how
you have reported you were feeling at each therapy session.
This “red” alert indicates that, during this past week, you
have been feeling more discomfort and pain than is typical
for a person at this time in therapy. This lab test analysis sug-
gests that we need to make sure that we address the reasons
why you are feeling so much worse than when you started.
That is why you were asked to fill out the second measure.
[The male therapist can see from the CST alliance measure that
the client has identified problems with the therapeutic bond as well
as some social support items.] Will you explore with me what
has happened that is so upsetting?
Client: It’s about my mother. I called her again this week so that
she could help me choose my wedding dress. I thought she
was on board with me after our last fight about my wedding
plans. Instead of finding times to go shopping, she immedi-
ately began asking me if I was sure Kennichi was right for
me. She went into a long tirade about all the reasons he
was completely wrong for me and even accused me of being
desperate. It was really hurtful again, only this time I feel I
have to give up on her.
Therapist: You just feel really that there is very little hope that your
mother and family will accept your decision and welcome
Kennichi. It’s hard enough to make this choice and go for-
ward, but now you feel really on your own and time is run-
ning out.

Client: Yes. But there is more. [25-second pause] It is hard for me to
talk about it with you. Last week in therapy when I showed
you pictures of my wedding dress and asked for your advice
about the best one, you acted as if I was wasting your time
and should not have asked for your advice about something
so trivial. I just felt so alone, that you didn’t understand what
I needed, and that I was being silly by talking about dresses.
I started to wonder if you thought my marriage was a mistake
too. I felt abandoned.
Therapist: So I really let you down and made you feel like you were being
silly. I guess it was like nobody was on your side, including me.
You gave me a chance to support you, and I blew it.
Client: Yes, I realize you are not family or a girlfriend, but I had
nobody else to turn to and you looked so confused at being
asked.
Therapist: I am really sorry that I did not get the pain you felt over your
mother’s persistent efforts to talk you out of marriage. My fail-
ure to recognize the meaning of your turning to me with talk
about your wedding plans was a blunder. Thanks for telling
me, and please give me another chance. I can see that you
are really feeling very alone.
Client: Well, I appreciate your apology. It helps. . . . Can you stand
in for my mother?
Therapist: Well, to tell you the truth, I think one reason I did not appre-
ciate the meaning of getting the right dress is that I doubt
my ability to know what looks best. But I guess you may
feel this way yourself—that you don’t really know, on your
own, what you really like. [From here, the therapy moves ahead
into issues of autonomy and self-doubt, because the therapist was
able to address the therapeutic alliance rupture and its deeper
meaning.]
Although some humanistic therapists may feel uncomfortable start-
ing a session with test report information, research has suggested that this
kind of addition to routine care is likely to improve client outcomes by
making therapists aware that the client is not making expected improve-
ment and by identifying alliance and social support problems. We believe
that humanistic psychotherapies might be supplemented by integrating
concepts and methods from other therapeutic approaches. This is likely to
be most effective when clients are engaged in the decision-making process
and the therapist proposes alternatives for their consideration, thereby
leaving to clients the ultimate decision about whether to try what the
therapist offers.

Another recommended change supported by research comparing
behavior–CBT therapies with humanistic treatments suggests that clients
with anxiety (in this case, panic) may benefit from psychoeducation about
panic and autonomic arousal. This is illustrated through the case of Brent,
who has seen his therapist on two occasions and described experiences that
seem to fit panic disorder.
Session 1 (halfway through):
Client: Last night, for no particular reason, I began to feel terrified—
scared out of my mind. This feeling just came out of nowhere.
I started to breathe very rapidly and thought I might be hav-
ing a heart attack and might die. My heart was pounding. I
also felt pain in my chest. Soon it also felt as if I was losing
my mind. This has happened to me before, and I went to
the hospital. They said it was not a heart problem and that
I shouldn’t worry, that it was all in my mind. Now it has
happened again and again. I am really scared something is
seriously wrong with my body and mind.
Therapist: This was very terrifying—it felt as if you were really going
out of control or might die at any minute.
Client: This is really quite embarrassing to talk about, and I wouldn’t
bother you with it, except now I am starting to skip work
because, if this happens at work, people are going to think I
am crazy. I have to get control of this. I can’t go through this
again.
Therapist: You don’t like anybody to see that you can be this terrified,
and you are starting to doubt if you have any control; you
think perhaps there is something really physically wrong
with you and this might happen again.
Client: Yes, exactly.
Therapist: Can you tell me what the situation was like when you had
the last panic?
Client: Well, it was about 7:00 p.m., and I came home. Nobody
else was there, and I remember starting to feel kind of light-
headed. Up to that point I was fine. Then the panic hit real
fast, like just out of the blue. Just before that there was a
sense of my room being off center or a little unreal, not quite
right. My hands began to clam up. And I remember earlier
in the day I thought I might lose control.
[Note: Therapist continued for half an hour with Brent by describing
the classic symptoms of panic and trying to gain appreciation for
his internal experience, patterns, and the sequences of his panic.
The therapist then decided that the client might benefit from some

psychoeducation about anxiety and panic in the second half of
the session.]
Therapist: You know, Brent, that what you are experiencing and describ-
ing is called a panic attack. For you to get rid of panic, it might
be helpful if we discuss what we know about its causes. Would
this be OK?
Client: Yes. I am glad somebody seems to know what is wrong with me.
Therapist: There is a small but powerful part of your brain that is in
charge of protecting you from danger, called your amyg-
dala. If you hear a noise at night in unfamiliar territory, your
amygdala is the part of your brain that. . . .
[Therapist explains the speed with which the amygdala works, how
it stimulates glands and hormones, heart rate, etc., stopping occa-
sionally to make sure Brent can make sense of the ideas that are
being presented, including the automatic, instantaneous nature of
the actions that it performs—including most of the signs that led
him to the hospital.]
Therapist: We believe panic is a false alarm signal generated by a part
of your brain that is in charge of protecting you from danger.
I will give you a handout of what we just discussed, so that
you can review this information at home, but first can you
say what you are making of what we just discussed and what
you are feeling now?
Client: Well, I feel relieved to know that I am not having a heart
problem and there is a reasonable explanation for losing
control and a way to fix this problem. I guess if I could figure
out what is triggering my amygdala, then I wouldn’t be so
scared. I am wondering if it will take long.
Therapist: Almost everyone who has panic and who gets help gets
much better in weeks, and I believe that this will also hap-
pen in your case. I can hear some relief already in your voice.
Just realizing that what you are going through is not a heart
attack, but a fear response that includes a rapid heart rate,
tightness in your chest, a sense of unrealness, is a good start.
Your amygdala can trigger all these symptoms. Even though
you can realize your heart is OK, it is not clear just what is
activating your amygdala to send danger signals when you
are really not in danger.
Client: You know I wonder if it has something to do with being
alone. I realize the first time I felt so scared was when I was
about 12 years old, and my parents asked me to stay home

alone when they went out, and I heard some noises and
thought I saw something move in the other room. It was like
a shadow or ghost or something. I thought it was going to get
me. I was so scared that I wet my pants. I was too ashamed to
tell my parents what had happened. Since then I have felt
scared coming home to an empty house.
Therapist: I hear some apprehension now, almost as if you are feeling
some of that old fear. And it strikes you that, if you are not
having a heart attack when you panic, it could be related
somehow to this early experience of fear that something,
someone, was going to get you. This was a case of your
amygdala warning you of danger. You were just as scared
as if something or someone was really there. I wonder what
would happen right now if you took a couple of deep breaths
and had the thought that you are safe or OK. . . . Yes, just
like that.
[The therapist introduces deep breathing as a way to reduce anxi-
ety, thus allowing Brent the experience of reducing his apprehen-
sion by consciously changing his breathing.]
Client: Yes, I can sense that I am becoming more relaxed. The
breathing really helped, because my heart rate was getting
up there. Now I feel safer, more relaxed.
Therapist: During this next week, would it be possible for you to take
some deep breaths when you start to feel apprehensive or
anxious? Breathing deeply a few times will be a way for you
to tell your body and your amygdala that you are not in dan-
ger. So it could help to consider the idea that you are hav-
ing false alarms, that your brain is reacting as if you are in
danger and provokes physical reactions like a racing heart.
When you start to panic, you also start to think very scary
thoughts like “I’m losing my mind.” If you would be willing,
we can further explore your physical reactions, your behav-
ior, thoughts, and how all these relate to your feelings about
yourself. In this way, we can start to understand and change
panic. Are you willing to try this out to see what effect it has?
Client: Yes. I would like to experiment and see. I must say I feel
hopeful right now, kinda like I am not facing this on my own
and also that getting so scared does not mean I am weak or
necessarily losing control.
Therapist: We might be able to make even more sense out of what is
triggering your panic if you learn how to use breathing to
reduce physiological arousal.

SUMMARY AND CONCLUSIONS
Humanistic psychotherapies, particularly person-centered and emotion-

focused treatments, rest on a strong empirical base dating back to the 1940s.
This empiricism led to the first recordings of actual therapy sessions and opera-
tionalization of Rogers’s facilitative conditions in the form of reliable rating
scales. In addition, therapy processes were studied through the use of client self-
report, judge-rated processes, and therapist-reported theoretical constructs. In
the current review, we found substantial evidence for the correlation between
therapist attitudes and the outcomes of humanistic psychotherapy, including
reliable estimates of the actual strength of these correlations. In recent decades,
researchers of the experiential psychotherapies have turned their attention to
quantifying the amount of change manifest in clients undergoing humanistic
treatments, comparing these outcomes with changes that arise spontaneously
over time, are evoked by placebo controls, or result from competing treatments.
According to Elliott et al. (2013), whose meta-analytic review is the
most recent analysis of the evidence base for humanistic therapies, there were
more than 200 studies. Consistent findings over the decades have shown that
humanistic therapies are more effective than no-treatment control condi-
tions and account for most of the changes observed in clients during and after
therapy, excluding the contribution of the clients themselves and therapists as
individuals. A majority of clients who enter the humanistic therapies (those
that have been studied) improve and maintain gains 12 or more months after
treatment on the wide variety of standardized measures used to operational-
ize mental health functioning. We conclude that recent studies evaluating
humanistically oriented treatments deserve recognition by the field of psy-
chology in general and in future health care policies; they are well within
the mainstream of evidence-based treatments. Clinicians who practice such
treatments can rest assured that extensive evidence backs up such approaches.
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3
QUALITATIVE RESEARCH AND
HUMANISTIC PSYCHOTHERAPY
HEIDI M. LEVITT
It is not accidental that the vanguard of qualitative research in psychol-

ogy is largely composed of humanistic psychologists. They have developed
and been primary proponents of the major approaches to qualitative methods
advanced in psychology over the past 50 years. These approaches include
phenomenology (Churchill & Wertz, 2001), task analyses (Greenberg, 2007),
appreciative inquiry (Anderson, 2004), grounded theory (Rennie, 2000),
hermeneutic methods (e.g., Elliott, 2001), heuristic research (Moustakas,
2000), and narrative approaches (e.g., Angus & McLeod, 2005; Josselson
& Lieblich, 2001). In addition, humanistic psychologists have broadly pro-
moted qualitative research methods and developed strategies for their assess-
ment in psychology (Elliott, 1986; Elliott, Fischer, & Rennie, 1999; Levitt,
This chapter is dedicated to the memory of David L. Rennie, who left a legacy of scholarly contributions
in both humanistic and qualitative psychology. I thank Ethan Lu and Fredrick Wertz for their comments
on points of this chapter.
http://dx.doi.org/10.1037/14775-004
S. Rubin (Editors)
81
2015; Rennie, 2012; Stiles, 1993). The close ties between the humanistic
worldview and qualitative ontology and epistemology have encouraged the
development of these approaches.
The strong connection between qualitative approaches and humanistic
psychotherapies and psychotherapists can be traced to their foundational
values. Qualitative research, sometimes termed human science, refers to scien-
tific approaches that have been developed to deal with the distinct challenges
of studying the subjective aspects of people that distinguish them from material
objects. Rennie (1995) observed that all psychological research is embedded
within rhetoric—that is, the art of persuading readers to share a particular point
of view. Along with others (e.g., Bazerman, 1987), he described the traditional,
quantitative, scientific praxis as based on disciplinary standards requiring work
to be presented in objectivist formats if it is to be recognized as credible—
thereby avoiding discussion of researchers’ perspectives or the mutual influ-
ence of participants and researchers. Human science rhetoric is different. Its
subjectivist framework assumes that researchers have expectations and hopes
about their work and that culture and language can sensitize investigators to
certain concepts and associations at the expense of others—that is, it assumes
that researcher–participant influence is unavoidable. As a result, engaging in
explicit consideration of researchers’ reflexive processes increases the rigor
within subjectivist rhetoric. Given these different approaches, a discussion
of ontological and epistemological foundations is in order.
ONTOLOGICAL AND EPISTEMOLOGICAL PREMISES

OF METHOD AND RHETORIC
Researchers have categorized qualitative research approaches in differ-

ent ways. Guba and Lincoln (2005), for one, have organized perspectives of
modern-day qualitative researchers into four major groupings: positivist, post-
positivist, constructivist–interpretive, and critical–ideological (see Morrow,
2005; and Ponterotto, 2005a, for further discussion). Although this rubric
has gained currency, distinctions among ontology, epistemology, and method
are not clear-cut (Staller, 2013); moreover, this type of organization does not
comprehensively make room for all possible qualitative methods, with some
researchers moving toward pragmatic approaches and arguing that qualita-
tive researchers should focus on methodology rather than on ontology and
epistemology (e.g., Morgan, 2007). Nonetheless, I will work with this tax-
onomy because it is helpful in considering a few of the central differences in
perspectives among qualitative researchers today. To exemplify these some-
what abstract ideas, I describe how adherents from each perspective might
approach the study of the therapist–client relationship.
82 heidi m. levitt

In the discussion to follow, ontology refers to the nature of being. In psy-
chology, this question tends to be framed in relation to the extent to which
reality is thought to exist independently of observers (i.e., the realist side
of the continuum) or the extent to which understandings are constructed
based on an aspect of experience such as history, language, or culture (i.e., the
relativist side). Epistemology refers to the question of what knowledge is and
how researchers can acquire understanding. Often, this issue is understood in
terms of whether scientists are seen as separate from their research participants
and able to observe phenomena without bias (a dualist, objectivist position)
or whether their perspectives unavoidably influence their research and their
participants, in which case discovery arises, in part, through mindful attention
to this interactive process (a holistic, subjectivist position). Although these
ontological and epistemic positions are presented sometimes as incommen
surable, many philosophical theories are based on combinations of them (e.g.,
Margolis, 2007).
Postpositivist Approach
This approach evolved from a natural science framework, based in the

study of the physical world. The logical positivist perspective, originating at
the beginning of the 20th century, held that knowledge should be founded on
logical and mathematical inferences from direct sensory experiences, culmi-
nating in laws of explanation and prediction. This approach supplanted earlier
perspectives that had included the development of human science traditions
and focused investigation on subjective experience (Danziger, 1990). In con-
trast, the new positivist approach prompted researchers to generate models of
reality that were accurate, specific, and unequivocal.
In modern times, postpositivist perspectives have become the estab-
lished approach to psychological research. The ontological approach therein
holds that there is a reality external to perception and theory, although it is
not completely logical because of limitations in measurement and perception.
The epistemological position that flows from this stance is both dualistic, in
that it assumes that scientists are independent from their subjects of study, and
objectivist, in that scientists tend to focus on maximizing their ability to appre-
hend reality (e.g., improving measures to enhance predictive abilities toward
the end of theory falsification) rather than on making explicit the subjec-
tive processes inherent in formulating and conducting research. The goal is to
reach as true an understanding of reality as possible, with the underlying prem-
ise that research findings should converge around this reality. Because this
postpositivist approach underpins most current psychological research, its
assumptions are pervasive and may be mistaken as requirements for scientific
practice—creating challenges for researchers using other approaches to science.
qualitative research and humanistic psychotherapy 83

Methods of research that rely on this approach include hypothetico-
deductive models that use statistics to analyze data and develop findings from
such methods as correlational, experimental, and quasi-experimental. These
methods tend to emphasize commonalities in experience across participants—
looking at statistical means, rather than at ambiguities or contradictions within
participants’ experiences. Examples of rhetorical devices include the use of
mathematical representations and writing in third-person language. These con-
ventions suggest the lack of bias in the researchers and minimize the appear-
ance of investigators’ influence on participants.
Using this approach, humanistic researchers studying therapist–client
relationships have generated a comprehensive body of quantitative research.
Examples of gains from this research approach include the development of
alliance measures (Horvath & Greenberg, 1989) and the convergence across
clinical experiments documenting the strong impact of the therapeutic alli-
ance on client outcome (see Horvath, Del Re, Flückiger, & Symonds, 2011),
as well as the randomized clinical trials demonstrating a body of empirical
support for emotion-focused therapy approaches (e.g., Elliott, Greenberg,
Watson, Timulak, & Freire, 2013). The central place that the alliance enjoys
in the understanding of common factors within effective therapy can be
largely credited to these quantitative humanistic contributions.
Examples of Postpositivist Qualitative Research

and Clinical Implications
Although human science research is generally situated within one of

the approaches other than a postpositivist one, qualitative researchers may
make use of postpositivist frameworks in different ways. For instance, Clara
Hill (2012) drew on both postpositivist strategies (e.g., using external audi-
tors as checks and quantifying the number of participants who contributed
an idea toward a given finding) and constructivist ones (e.g., acknowledg-
ing researchers with multiple realities coming together to share perspectives)
in her consensual qualitative research approach. This combination of strate-
gies holds great appeal for quantitative researchers—likely contributing to its
becoming a dominant qualitative method in the study of psychotherapy.
Postpositive strategies are also used in multimethod approaches to
research ideas such as developing third-party quantitative measurements of
constructs on the basis of qualitative studies. These might allow for the reli-
able measurement of observable behaviors that are centered on empirical
findings about clients’ and therapists’ experiences in session. Examples can be
found when researchers conduct qualitative research to inform quantitative
studies, to generate items for measure development.
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For example, Levitt (2001) conducted a qualitative study on clients’ expe-
riences of silences that helped therapists differentiate productive, neutral, and
obstructive forms of silence, leading to the development of a process measure,
the Pausing Inventory Categorization System. This measure is unique for its
ability to establish both interrater and client–rater reliability—an advantage
deriving from its being based on interviews with clients. Also, it has gained
additional support from both effectiveness and efficacy datasets and has estab-
lished an empirically based sampling strategy (e.g., Frankel, Levitt, Murray,
Greenberg, & Angus, 2006; Stringer, Levitt, Berman, & Mathews, 2010).
Therapeutically, it can guide therapists to respond strategically to different
forms of silence, so that they can structure and encourage silences resulting
from client introspection and act to inquire directly when silences indicate a
process of disengagement or a concern about the therapy process. More detail
on this process is provided toward the end of the chapter.
Task analyses are another example of humanistic qualitative research
that similarly incorporates both the constructivist development of models of
therapeutic task resolution and their quantification and testing (e.g., Pascual-
Leone, Greenberg, & Pascual-Leone, 2009). This innovative method gener-
ates a map of the steps that therapists take in good outcome interventions,
comparing them with poorer outcome interventions. As an example, Pascual-
Leone and Greenberg (2007) described how clients work through the experi-
ence of global distress within experiential psychotherapy. They generated a
model of the resolution of distress and then tested it, affirming that distinct
sets of emotions emerged in the patterns that the model predicted. They found
that clients had two dominant pathways toward resolution.
For one, their distress could be differentiated into a sense of fear and
shame that, through exploration, is translated into a negative self-evaluation
and an existential need for valuing the self that is then soothed by developing
a sense of the self as lovable and worthy or, for another, the sense of distress
could lead to a sense of rejecting anger that pushes away a noxious other,
which evolves into a more positive sense of assertive anger and self-soothing.
In both cases, clients experienced sadness about being hurt or about a sense
of loss and then came to a place of acceptance and belief in their own agency
and coping.
The clinical implications for this type of research are numerous. The
results may sensitize therapists to the experiences of clients that underlie dis-
tress. In addition, these findings provide a road map that permits flexibility, so
that therapists can follow the different paths that tend to emerge for the cli-
ents. As a research strategy, this mixed-methods approach goes beyond experi-
mental strategies that only compare outcomes of therapeutic interventions or
orientations, because it also provides empirical support for the processes via
which outcomes are reached.

Because the postpositivist framework is the dominant approach in psy
chology, qualitative researchers may find themselves accepting (or being
asked to accept) these assumptions to increase the perceived rigor of
research—however these efforts might risk reducing the credibility of their
work when seen from different approaches. For instance, adding in inter-
rater correlations can enhance reliability from a postpositive perspective, but
the same rating system might reduce complex phenomena to more super-
ficial assessments. This process might be amenable to reliability calculations
that can help in establishing a coding system but preclude gains desired by
constructivist researchers—that is, the development of rich descriptions and
interpretations by an attuned analyst immersed in the data. In these cases, it
can be helpful to consider the nature of the research question and how well it
is furthered by the different goals of these approaches.
Constructivist–Interpretive Approaches
In contrast to the more realist postpositive position, adherents of

constructivist–interpretive approaches hold a more relativist ontological
position in which they maintain that what is real is coconstructed with oth-
ers and that people can hold different experiences of reality that are equally
valid. Although both interpretive and constructivist researchers are inter-
ested in understanding the meaning of an experience for their participants,
interpretivists tend to draw meaning forward by asking questions; their rela-
tionship with participants is more distant. Constructivist researchers tend to
join with the participants to cocreate meanings in the process of dialogue (see
E. N. Williams & Morrow, 2009).
Following from this assumption, researchers tend to be more invested in
seeking out how contexts and social experiences influence experiences than in
trying to find support for one understanding of reality in contrast to another.
This epistemological perspective is rooted in the subjectivist understanding
that researchers are also functioning with assumptions that can influence the
research process and that these assumptions need to be carefully examined
to decrease their influence on the data analysis. Constructivist–interpretive
humanistic researchers studying the therapist–client connection have also built
up a sizable body of research examining both therapists’ and clients’ differing
perspectives on psychotherapy. These methods tend to focus on developing
contexualized understandings of experiences, with attention to the ambi-
guities, complexities, and variations that characterize subjectivity. Methods
that have been used by humanist researchers that can be framed within
constructivist–interpretive frameworks include approaches to phenomeno-
logical analyses (e.g., Smith, Flower, & Larkin, 2009), grounded theory analy-
ses (e.g., Charmaz, 2006; Rennie, 2000), intuitive inquiry (Anderson, 2004),
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thematic analysis (e.g., Braun & Clarke, 2006), and narrative approaches
(e.g., Angus & McLeod, 2005).
Constructivist–interpretive researchers use a variety of rhetorical strat-
egies. These strategies include writing in first-person language, reflexively
analyzing the influence of their own perspectives on their research, focusing
on experiences of ambiguity and conflicting interpretations, and developing
understandings that are contextualized by culture, place, and time. The use
of these strategies befits a more relativist ontology (i.e., because of the under-
standings that experience is in flux, that it is ambiguous, and that it can be
located interpersonally) and a subjectivist epistemology (i.e., that researchers
inescapably have assumptions).
Examples of Constructivist–Interpretive Qualitative Research

One of the most influential psychotherapy qualitative research studies

has been David Rennie’s study of clients’ experiences in sessions. As his meth-
odological work defended the rigor and philosophical integrity of qualitative
methods (e.g., Rennie, 2012), his studies of clients’ experiences popularized
grounded theory in the psychotherapy research community. In particular, his
1994 grounded theory study of client deference—finding that clients submit-
ted to therapists’ professional expertise in sessions even when it conflicted
with their own experiences—has been widely cited.
Rennie (1994a, 1994b) provided the following example in which a cli-
ent was interested in uncovering why she was pitying herself. Her therapist,
usually sensitive, appeared uninterested in this question. He wanted her to
accept her self-pity and work from there. The session was exploring a con-
cern of the client that she was not responding well to the competitiveness of
university life. She had remarked, “But I want to just tell myself, ‘You’re here,
so just do it.’” The therapist had then replied, “Is there something stopping
you?” to which the client had responded, “Me.” The therapist then shifted
the client back to a behavioral focus by saying, “Or just doing that,” refer-
ring to her engagement in university life. The client paused for a long time
after this redirection because she interpreted it as another reminder that she
should engage in action instead of continuing to dwell on the “why” ques-
tion. Nevertheless, she had not been able to help herself. Inwardly, she had
wanted to try to get to the bottom of why she was feeling and acting the
way she was and, yet, because of the therapist’s constraint, the client had
felt that she could not once again raise the “why” question (Rennie, 1994b,
p. 432). In her interview, the client described that, although she appeared
to continue along the therapist’s line of inquiry, she internally continued
to link up the ensuing discussion with her own question throughout the

session, while hiding this activity from her therapist (Rennie, 1994b). As a
result, she was not as fully engaged in the therapeutic exploration during the
remainder of the session.
This study offers a window onto the internal life of the client and rec-
ommends to therapists that they be cautious about their confidence based
on their professional expertise and explicitly check in with clients to ensure
that the tasks of the sessions are actually the tasks in which the clients wish
to engage. Also, talking directly with clients and inviting them to communi-
cate when the therapy seems to veer away from their interests may be crucial
because they may otherwise feel captive to the therapist’s agenda. In this way,
constructivist–interpretive approaches can provide insight into how a dia-
logue is generated and how meaning is coconstructed within psychotherapy
dialogue—by both the client and the therapist.
Critical–Ideological Approaches
In psychology, critical and ideological approaches are often framed in

relation to feminist and multicultural approaches that critique mainstream
understandings of the nature of reality. The ontological approach of these
theorists holds that reality is interpersonally constructed, but also that it is
mediated through structures of power that have come to exist through histori-
cal and social contexts. These structures may be hard to recognize, let alone
challenge, because they have become part of everyday social fabric. Their epis-
temological approach is guided by the understanding not only that researchers
are inherently value laden but also that they should be value driven. Instead
of trying to hold their values in abeyance or reduce their influence on the
analysis, these researchers are working to use their values to effect change in
their participants and others—typically a form of empowerment in the face
of oppression.
Although these approaches can use quantitative methods as well to
reach their goals, qualitative methods that are commonly situated within
critical–ideological approaches and have been used by humanistic psycholo-
gists include discourse analysis (e.g., Gergen & McNamee, 2000), feminist
or multicultural models (see Van de Kemp & Anderson, 1999), and partici-
patory action research (Goodley & Lawthom, 2005). The rhetorical strate-
gies used are similar to constructivist–interpretive methods, but attention is
focused on how power differences influence the research process. These strate-
gies closely attend to issues related to power and oppression and how they can
become invisible within social discourse and practices. They might explore a
phenomenon from multiple vantage points to study intersections of different
discourses—for instance, oppression and privilege. These studies may include
participants deliberately selected from across different strata of society; for
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example, families, peers, police, and teachers might all shed light on police
harassment (Fine et al., 2003). These researchers explicate the multicul-
tural or feminist values that they bring to their analysis to try to disentangle
complexities within marginalized identities and experiences in relation to
social power.
In the context of the study of the therapeutic relationship, these research-
ers might be interested in how a marginalized status influences experience in
therapy. Is a dominant-culture therapist able to understand the significance of
a client’s issue within a minority culture? Do clients experience apprehension
influenced by a historical context in which other dominant-culture people
have not understood their lives? A goal for critical–ideological researchers is
not just to create understanding but also to empower the community under
study to develop a new discourse and ways of dealing with power-related issues.
Examples of Critical–Ideological Qualitative Research

A lovely example of this research comes from McKenzie-Mavinga’s

(2005) study focused on Black issues in postgraduate counselor training. She
conducted action research in which she interviewed therapists and trainees,
uncovering both the need to find a voice to discuss the different effects of rac-
ism and recognition trauma when both White and Black interviewees recog-
nized the impact of racism in their lives but felt stuck and unsafe in exploring
these issues more deeply. The work resulted not only in an understanding of
how race issues influence therapy training, but also in changing the way race
was dealt with within the training community at hand.
Research by Gone (2013) has provided another example of this approach.
He interviewed both clients and staff in a Native American healing lodge,
where he learned about how the process of confession and catharsis could
affirm a practice of introspection and a reclaiming of heritage that could
help people resist the pathogenic effects of colonization. His findings went
beyond a description of the therapeutic process to make systems-level recom-
mendations about how psychologists might work with these communities. He
encouraged psychologists to partner with indigenous programs to determine
outcomes that might be desired by a given community and develop culturally
appropriate interventions.
In both examples, the outcomes of the work go beyond the development
of research to inform the way a community solves a problem in its midst.
Other examples of outcomes include the development of new mental health
resources for minority-culture clients or political actions that might assist with
the accessibility of mental health services. In any case, the research ques-
tions, the methods, and the outcomes tend to be guided by the collaboration

between the researcher and the community at hand, so that research is focused
on questions that are central to the community, use processes that are sensitive
to issues of power, and produce results that are desirable. These approaches
are particularly relevant for humanistic researchers and practitioners who are
committed to social justice issues (see Jenkins, 2001).
CONVERGENCE IN HUMANISTIC AND

HUMAN SCIENCE APPROACHES
Therapists who practice and study different psychotherapy orientations

have evolved research cultures with different histories and values (e.g., Hill
& Corbett, 1993). The cognitive–behavioral tradition, for instance, which
has evolved within medical contexts, has made foundational methodological
contributions to the development of experimental and clinical trial technolo-
gies. This therapy’s objectivist focus on symptom removal has led to the devel-
opment of the majority of modern outcome measures used to assess therapy
change, even across different therapy orientations (Levitt, Stanley, Frankel,
& Raina, 2005). The psychodynamic tradition, which developed the case
study, has also developed innovative research tools that pay close attention
to the idiographic within clients’ cases and render it accessible for study (e.g.,
Luborsky & Crits-Christoph, 1997). In contrast, psychologists who ascribe
to humanistic orientations have tended to develop process measure tech-
nologies (e.g., Klein, Mathieu, Gendlin, & Kiesler, 1969; Rice & Wagstaff,
1967) and qualitative research approaches (Greenberg, 2007; Rennie, 2000).
Approaches to psychotherapy have developed different research cultures that
best reflect the ways that they understand therapy (or, in other words, their
ontological beliefs about the subject and their epistemological beliefs about
scientific inquiry).
Humanistic approaches, then, are often associated with human science.
Carl Rogers’s work (e.g., 1961) provides some explanation of this connection.
He described the development of a relativistic self in which people develop
understandings and values that are shaped in relation to their individual expe-
riences and the conditions of worth held by others. He had a profound appre-
ciation of the individuality of experience that came forth in his therapy and
writings: “The only reality I can possibly know is the world as I perceive and
experience it at this moment. The only reality that you can possibly know is
the world as you perceive and experience it at this moment” (Rogers, 1980,
p. 96). He argued that individuals have perceived realities that differ from
each other and from any external reality.
In terms of critical consciousness, Rogers (1961) viewed the diversity
of clients’ personal realities as central to his theory. His focus was not on the
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systemic sphere and the ways social power can be oppressive, but on the
personal sphere and the ways external conditions of worth influence each
person. He oriented therapists to center on the uniqueness of each individual,
encompassing the way they experience themselves in relation to their cul-
tural background, gender, sex, family, and interpersonal systems. His belief
in unconditional positive regard encouraged respect for and honoring of
differences evidenced by each client, whether due to the client’s culture,
family, or person. Although in Rogers’s era there was little focus on explic-
itly addressing the role of cultural oppression within psychotherapy, Brown
(2007) noted that
cultural competence, when the specifics of what one does with a specific
group are stripped away, is about a therapist’s willingness to take a stance
of respect and empathy for the experiences of someone who is socially
and experientially “other.” (p. 259)
Genuineness, which Rogers was first to acknowledge as an important vari-
able, is equally core to multicultural competence, especially the aspect of
genuineness that emerges when a psychotherapist is willing to admit what she
or he does not know, inviting the client to be the expert and authority. This
shedding of the expert role and investment in empowering clients to solve
their problems by drawing on their local wisdom is very much in keeping with
a critical perspective.
Rogers’s career ended before qualitative methods became more com-
monly used, but he wrestled openly with the place of the subjective within
the positivist science of his day, critiqued logical positivism, and directed
researchers toward the emerging field (Rogers, 1989/1985). He wrote,
Science is not an impersonal something, but simply a person living
another phase of himself. . . . If I am open to my experience, and can
permit all of the sensings of my intricate organism to be available to
my awareness, then I am likely to use myself, my subjective experience,
and my scientific knowledge in ways which are realistically constructive.
(Rogers, 1961, p. 223)
It was important for him to work out a solution, even though he acknowl-
edged that it was a partial solution, to how he could approach science as a
person first (Coulson & Rogers, 1968).
Fischer (2006) described the enduring affinity between human science
and humanistic inquiry as resulting from the humanistic interest in respect-
ing and exploring different experiences of living in the world, appreciation of
embodied experiencing, and admiration of holistic understanding. She also
cited the appreciation of Buber’s (1923/1970) kind of respect for the “thou”
in one’s participants and the placing of researchers’ outsider expectations into
abeyance as beneficial values for inquiry.

Another reason for this convergence, Rennie (2007) suggested, is that
both qualitative methods and humanistic psychology have been based on
methodical hermeneutics—the development of method related to under-
standing an interpretation of text or communication. He traced in both Carl
Rogers’s and Abraham Maslow’s writings a tacit endorsement of hermeneu-
tics, citing Maslow’s (1967) interviewing and analyzing data related to people
he came to see as self-actualized and Rogers’s development of a theory of
personality (e.g., 1961). Indeed, humanistic researchers have had a long-
standing penchant for qualitative research because of the convergence in
their ontological and epistemological perspectives. Perhaps it is because of
their roots, attitudes, and foundational ways of making meaning that human-
istic psychologists have been at the forefront of qualitative approaches to
psychology.
REVIEWS OF QUALITATIVE PSYCHOTHERAPY RESEARCH
Although still a minority approach, education on and the use of qualita-

tive methods have been steadily increasing in psychology, especially in coun-
seling psychology (Ponterotto, 2005a, 2005b; Rennie, Watson, & Monteiro,
2002). One reason for the increased popularity of qualitative methods might
be because of development of interest in funding multimethod projects by
the National Institutes of Health (Office of Behavioral and Social Sciences
Research, 1999). There has been a focused adoption of these methods by
psychotherapy researchers, perhaps because of the subjective nature of the
psychotherapy experience and the ability of qualitative methods to explore
experiences internal to therapists and clients. At this point, a number of reviews
of this literature have been conducted.
Until 2000: Rennie’s Review of Grounded Theory Research
In the first edition of Humanistic Psychotherapies, David Rennie (2002)

reviewed the grounded theory research literature on psychotherapy at that
time. Because this budding literature was in its early stages, he was able to
describe individually the findings of those studies. His review portrayed the
literature as divided by its focus on entire psychotherapies, on an hour of
psychotherapy, on spontaneous events within psychotherapy such as psycho-
therapy misunderstandings (e.g., Rhodes, Hill, Thompson, & Elliott, 1994),
or on therapist-directed tasks such as the analysis of problematic reactions
(e.g., Watson & Rennie, 1994).
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Three main findings were identified with associated clinical implica-
tions emerging from this research review:
1. Clients’ agency and self-awareness came forward as central factors
in that clients across the studies described being active within
sessions rather than passive recipients of therapists’ interven-
tions. This finding challenged the received causal model of psy-
chotherapeutic change, which emphasized therapists’ activity
in applying interventions to their clients. In contrast, clients in
these studies were found to use their therapists’ interventions
creatively by combining, transforming, rejecting, or ignoring
them in ways that were unpredictable.
2. The relationship between client and therapist was seen to be
crucial because clients described attending to it more than to
the techniques that therapists used. Accordingly, therapists
were encouraged to adopt a very nuanced view of the relation-
ship, to use transparency and congruence, and to check periodi-
cally on the state of the therapist–client alliance.
3. Clients in these studies reported being engaged in covert pro-
cesses of which their therapists were often unaware. Clients
were found to defer to therapists, even though they might
resist an idea internally. They were found to use stories and
distractions to steer therapists away defensively from sensi-
tive or threatening issues. Therapists were, therefore, encour-
aged to notice small signs of hesitation in clients and to
inquire explicitly about clients’ internal experiences in those
moments.
These findings were very supportive of humanistic approaches that tend
to privilege the relationship over interventions and that value clients’ self-
determination. They encouraged meta-communication about the interactions
in therapy, so that therapists could bring their genuine experience to the session
and learn about the clients’ internal world within it. The following transcript
excerpt provides an example of this process.
Therapist: It sounds like you are saying that you are feeling that things
are getting better now.
Client: Yeah. Sort of.
Therapist: What does it mean when you say, “sort of”?
Client: Well, I guess I do feel that I know more about what I feel, but
it still doesn’t feel good.

Therapist: Hmmm. I wonder what it would be like to keep exploring
the part that doesn’t feel good?
Client: I guess I’m worried about what happens if I continue to feel
bad, especially this week.
When clients are invited to discuss the process of continued exploration,
they can evaluate and consider therapy goals and describe any apprehensions.
Therapists then have the opportunity to reassure clients, process concerns, or
help clients decide on preliminary or new goals.
Rennie (2002) cautioned therapists about using meta-communication
too often because it can pull clients out of the therapy process, but he also
argued that it can help therapists learn about the internal processes that clients
may be masking within sessions. It can be easy for therapists to assume that a
session is going well when clients are appearing engaged and satisfied, which
means it can also be easy to misunderstand both the ways that clients might be
rejecting some of the interventions at play or the ways they might be creatively
generating new understandings that fit better in their lives. Bringing these ideas
to light can help the therapist better understand the client going forward and
allow a new level of connection between client and therapist.
It is notable how the qualitative psychotherapy literature has expanded.
Levitt and her colleagues, for instance, have conducted two recent reviews
of the literature focused on adult individual psychotherapies across qualita-
tive methods published in English-language journals. When looking at the
research based on data from the perspective of therapy clients in an ongoing
meta-analysis of the qualitative psychotherapy literature before 2000, Levitt,
Pomerville, and Surace (2013) identified only 11 studies before 2000, in con-
trast to 54 others published from 2000 to 2013. Reviewing research based on
data collected from therapists in a similar study, Levitt and Lu (2014) found
six studies before 1999 and then 72 from 2000 to 2013. The growth of this lit-
erature speaks to how well the qualitative paradigm appeals to psychotherapy
researchers.
Current Reviews of Humanistic Qualitative Psychotherapy Research
In contrast to Rennie’s (2002) evaluation, more recent reviews have

examined psychotherapy research across different qualitative methods. Elliott
(2002) described an unpublished qualitative review of five studies of 136 cli-
ents’ interviews or questionnaires related to their experiences in mostly
process–experiential psychotherapy, from which he derived two main cate-
gories (Jersak, Magaña, & Elliott, 2000). The first was called “vitalizing the
self ” and referred to changes related to greater contact with the emotional
self, along with increased self-esteem, self-control, and sense of power. This
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shift might parallel Rogers’s (1961) discussion of congruence, as clients learn
more about themselves and move toward developing greater correspondence
between their perceived self and their ideal self. The second category, called
“relocating the self in relation to the others/world,” related to clients’ bet-
ter sense of separation from and assertion with others, along with feeling
better able to engage and act with others in the world. For example, Gestalt
unfinished business dialogues are one intervention that can help clients to
reach these goals (e.g., Elliott, Watson, Goldman, & Greenberg, 2004). This
finding suggests that humanistic practitioners help clients not only to differ-
entiate their feelings and needs but also to learn how to use these insights to
guide interactions in their lives outside of therapy. This attunement, which
can help clients set boundaries and limits and learn to assert their needs, was
experienced as a gain by clients—one that may not be captured by symptom-
focused outcome assessments of change.
Timulak and Creaner (2010) conducted a review of humanistic qualita-
tive research based on 106 client reports. Their three main findings were that
humanistic psychotherapies led to (a) the development of a deeper apprecia-
tion for experiences within the self—such as hopefulness, peace, vulnerability,
self-compassion, resilience, symptom change, and empowerment; (b) a greater
appreciation of the self in relationship, characterized by feeling more sup-
ported, enjoying relationships, and becoming more assertive or tolerant; and
(c) a changed view of the self and others, resulting in greater insight and per-
sonal understanding as well as perspective taking and acceptance of others.
In particular, Timulak and Creaner (2010) noted that a helpful outcome
appeared to be that clients developed an appreciation for their own vulner-
ability and the usefulness of experiencing and accepting emotional pain in a
supportive context. Similar to the Jersak et al. (2000) review, this research is
supportive of the humanistic tendency in psychotherapy to move toward dif-
ficult experiences to develop self-awareness. This process can be challenging
for novice therapists who fear that encountering pain can damage clients. To
the contrary, these findings support the idea that coming to accept difficult
feelings is experienced as a gain by clients. It can be a stepping stone to becom-
ing able to identify their needs and making new decisions about how to deal
with pain.
A review of qualitative humanistic research by Elliott et al. (2013) was
organized into two main categories. In the first category, general in-session
psychotherapy experiences, they highlighted the innovative research of David
Rennie (e.g., Rennie, 1994a, 1994b; Rennie, Phillips, & Quartaro, 1988),
including his identification of clients’ reflexivity as the central function within
the therapeutic process (Rennie, 2004). In the second category, they high-
lighted the research on helpful and hindering moments in psychotherapy
(e.g., Grafanaki & McLeod, 1999; Timulak, 2003). They described the central

findings from this latter body of research as demonstrating that therapists’
empathic, relational, and experiential processing skills helped clients to
develop insight, empowerment, and self-awareness.
These findings are congruent with humanistic psychotherapy approaches
in their suggestion to therapists that keen attention to the therapeutic rela-
tionship is key. In particular, Elliott et al.’s (2013) review recommended that
therapists work to guide clients not only to identify emotional experiences
but also to contact them in session. This process of allowing for and encour-
aging the experiencing of feelings via empathy and a process of differen-
tiation within emotions can allow clients to gain clarity on what they are
experiencing. Noticing new emotions and experiences can help clients orga-
nize differently and make new decisions about their needs and relationships
(e.g., Elliott et al., 2004). Such an approach can also help therapists avoid
hindering events such as misunderstandings by developing clarity on clients’
internal experiences. Often this entails prolonged exploration, as depicted
within the following sample dialogue:
Client: I just feel so upset about how he always puts his work first.
Therapist: It is upsetting. Can you stay with that feeling? What does
that upset feeling feel like?
Client: Well, I feel like he doesn’t really care about me. Or like he
only cares about me when it suits him. After everything
important is done.
Therapist: Yes. What is that feeling of only being cared about second?
By the person who is supposed to love you most of all? Take
a moment and stay focused on it and see what words arise.
Client: It is really painful. I feel like a joke.
Therapist: It hurts. Can you feel that now? [Pause] Stay with it. [Pause]
Client: Yes. It feels embarrassing too. How can I be a strong woman
and also be treated this way? What if I keep accepting this?
What will happen to me and my sense of my self?
Therapist: It is hurtful, but also shameful and scary to think about how
the relationship might change you. [Pause] There are so
many strong feelings and some of them are hard to see.
Client: I feel all of those things. [Pause] And I don’t like feeling
ashamed about how I am acting.
Therapist: I wonder what that ashamed part of you is needing to hear
from you or to know from you.
Client: [Pause] I think I need to remind myself that he doesn’t want
to hurt me. It is his ambition and driven personality that first
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attracted me to him. I need to find ways to stay strong no
matter what relationship I am in. And maybe I should tell
him that I want more reassurance.
This in-depth exploration of internal experiences that characterizes humanis-
tic approaches can help therapists developed attuned responses and avoid mis-
understandings. For instance, a different client with a similar initial presentation
might discover through such an exploration that she is not just upset but is really
angry; she might be prompted by this insight to set limits in her relationships
and act to protect and distance herself from her partner.
In addition to identifying helpful and hindering aspects of therapy,
Elliott et al.’s (2013) review examined the extensive body of task analytic
research conducted by Leslie Greenberg and his colleagues (see Greenberg,
2007, for a detailed description of task analysis). This research has been used
to generate empirically based models of the different tasks in emotion-focused
therapy approaches. This modeling of the processes within tasks is a mixed-
methods approach, but it is grounded in inductive analyses of commonali-
ties across good outcome tasks in comparison with poor outcome tasks. As
described previously, these models provide guidance on how therapists can
best facilitate different therapeutic tasks. Indeed, they offer greater flexibility
than most manualized treatment approaches because they describe the mul-
tiple routes that clients are most likely to take within a change process, so that
therapists who see a client falter in one step can trace back to which steps
might be important to revisit or can engage alternate routes toward closure.
For instance, in the previous transcript example showing a therapist helping
a client resolve global distress (Pascual-Leone & Greenberg, 2007), if the
client’s exploration did not proceed from distress to articulating an underly-
ing experience of shame and fear, the model explicates an alternate route to
resolving global distress that the therapist could follow. In this second route,
exploration leads, via anger, toward an eventual stage of assertion and self-
soothing, concluding in acceptance and agency. By identifying the different
pathways by which a task can be resolved, task-analytic models allow thera-
pists to navigate fluidly the terrain of sessions.
Finally, the Elliott et al. (2013) review noted that the qualitative outcomes
were consistent with humanistic theories of change and that studies identified
client gains such as increased awareness, empowerment, self-compassion, and
appreciation of vulnerability. In contrast, humanistic quantitative outcome
research has traditionally relied on nonhumanistic measures to evaluate
outcomes (Levitt, Stanley, et al., 2005). The identification of outcomes
that characterize humanistic therapy can direct the development of coher-
ent ways to assess outcome within this approach. Given these procedures,
humanistic practitioners as well as researchers might want to keep in mind
that positive outcomes in humanistic therapy may be more complex than the

reduction of symptoms. For instance, they may include the acceptance of a
symptom or the transformation of a client’s relationship with the symptom.
Thus, instead of working to stop a client from crying, it might be that the
therapist finds ways to mourn a loss productively. Finding ways to encounter
a difficult emotion safely and value what it represents can become cherished
moments that enrich one’s lived experience. Providing an alternate model of
how to consider outcome, Daniel and McLeod’s (2006) qualitative research
found that person-centered therapists evaluated outcome by engaging in a
variety of process assessments throughout a session and then weighing these
together—a sort of hermeneutic model of assessment in which each piece of
data is understood in relation to the whole and to each other, thus permit-
ting complexity in conceptualization. These processes could include asking
clients to check internally on whether words or interpretations fit, checking
with clients before engaging in a task to see whether it is framed correctly, or
using methods that structure introspection, such as focusing (Gendlin, 2007).
Reviews of Qualitative Research Across Psychotherapy Orientation
Reviews of the qualitative psychotherapy research literature on clients

and therapists have found that most of these studies have either been con-
ducted with participants engaged in multiple theoretical orientations or have
not reported the orientation of the therapists (Levitt & Lu, 2014; Levitt
et al., 2013). Several reviews have been conducted to explore the qualitative
literature base that extends outside of humanistic approaches as well.
Timulak (2007) directed a meta-synthesis of seven qualitative studies
focusing on helpful events in therapy to identify central elements in this
literature. He found convergence with prior meta-analyses around the fol-
lowing helpful processes: (a) the development of new awareness, insight, or
self-understanding; (b) the formulation of new strategies to approach behav-
ioral change or problem solutions; (c) a sense of greater personal strength
or interpersonal empowerment; (d) relief due to a sense of acceptance by
the therapist; (e) the exploration of feelings and emotional experiencing;
(f) the sense of feeling understood by a therapist; (g) the clients’ involvement
and influence in the therapy process; (h) the implicit and explicit reassur-
ance and support from the therapist; and (i) the personal contact with the
therapist as another human being. Although these studies explored clients’
experiences across psychodynamic, cognitive–behavioral, and humanistic
approaches, most of the findings emphasized the importance of the therapeu-
tic relationship.
In 2010, Timulak conducted a second meta-synthesis of 41 studies that
made up the significant moments literature—a body of research spearheaded
by Robert Elliott (e.g., 1986) and his colleagues that asked clients to reflect
98 heidi m. levitt

on and describe what they experienced as important about a therapy ses-
sion. When looking at studies of individual psychotherapies, he found that
events related to insight and awareness appeared to dominate across the stud-
ies of helpful events, second to the interpersonal impact of the therapist,
such as feeling understood. Misunderstandings between therapist and client
and disappointment with therapists’ interventions were found to dominate
the unhelpful events. When the literature on clients’ and therapists’ percep-
tions of significant events was examined, it appeared that they often held
different interpretations of therapy events; in fact, interpretations matched
in only 30% to 40% of events, and these results are similar to those of recent
research (Levitt & Piazza-Bonin, 2011). Therapists appeared to attend more
to therapeutic work related to the development of awareness, whereas clients
attended more to relational factors within the sessions. These findings stress
how important it can be for therapists to check in with clients to develop an
understanding of their therapy experience.
This finding has profound clinical implications, suggesting that thera-
pists’ connection with clients may be compromised when they are focused on
the development of interventions and clients are concerned with the relation-
ship itself. Indeed, some of this research has suggested that feeling genuinely
liked may be among the most important experiences for clients in therapy
(Levitt, Butler, & Hill, 2006). It can be important for therapists to keep in
mind the central role of the relationship for clients, even amid the necessary
work of forming interventions and guiding the clients’ process toward new
understanding.
Also, Timulak (2010) found mixed results in looking at whether differ-
ent orientations influenced the events identified as significant. Many events
were identified across therapy orientations, but some seemed to correspond
with orientation goals—for instance, psychodynamic therapies more often
leading to awareness events and cognitive–behavioral therapies to problem
resolution events (e.g., Elliott, James, Reimschuessel, Cislo, & Sack, 1985;
Llewelyn, Elliott, Shapiro, Hardy, & Firth Cozens, 1988). Timulak, who con-
cluded that more research on nonhelpful events was needed, also emphasized
that many of the helpful events included the processing of painful and dis-
tressing experiences, indicating that what is helpful for clients often appeared
to go beyond the bounds of what is comfortable.
This last finding is congruent with the conclusions of a review of con-
structivist theories of resistance (Frankel & Levitt, 2006) that indicated that
therapists from constructivist traditions tend to view moments in which
clients felt distress, prompting temporary disengagement, as invitations for
further exploration. For instance, a therapist might stop to explore what was
painful about considering an issue to accept and understand it better. After
developing a relationship in which the fear of exploration can be discussed

openly, a client might experience the safety to delve further into a threat-
ening issue. Instead of scheming to overcome the resistance, humanistic
therapists can meet these moments by compassionately exploring clients’
emotions to understand their motivations better. An example of explora-
tion follows:
Client: I don’t know what else to say next. I just don’t know what I
am feeling.
Therapist: It can be hard to figure out what you are feeling. [Pause]
There is something hard about that.
Client: I’m not sure what you want me to say.
Therapist: It feels like you have to figure out what I want. It’s hard to
just stay focused on what you are feeling and notice what
feelings are inside you. Let’s see what happens if we just stay
focused for a little bit on what feelings you have. [Pause]
Client: I feel like pushing away. I feel scared. It’s hard to let myself
notice my feelings.
Therapist: It is hard. [Pause] But there is a scared feeling there. Can we

focus on that feeling for now?
In this example, a potentially constructive event begins with some challenging

work that helps a client move through an obstacle preventing introspection.
Helpful work can be painful at times.
A recent qualitative review of adult clients’ experiences of individual psy-
chotherapy, one that was not restricted by either type of qualitative method
or foci, examined 63 qualitative studies that included 1,031 participants in
total (Levitt et al., 2013). One striking preliminary finding from this study
was that a sizable amount of this research (13 of 63 studies, or 20.6%) was
focused on issues related to diversity and cultural differences—some of which
was conducted by humanistic researchers (e.g., Shelton & Delgado-Romero,
2011; D. Williams & Levitt, 2008).
Jenkins (2001) observed that a dilemma for humanistic psychology was
the way its individualist focus had kept it from being embraced by a multi-
cultural audience. At the same time, he indicated that humanism was really
not at odds with the multicultural movement because of its focus on dialecti-
cal and constructive beliefs that there may be alternate ways of construing
experiences. He argued that the humanistic emphasis on agency does not
need to reflect individualist separation from others but rather the engage-
ment of imagination about the experience of individuals who exist within
different (e.g., collectivist) social structures.
100 heidi m. levitt

This growing body of qualitative research seems to engage in just this
process of enlightening both clinicians and researchers about the experiences
of others. For instance, in Shelton and Delgato-Romero’s 2011 insightful
research on microaggressions in therapy, they classify seven experiences
that can generate distress for lesbian, gay, bisexual, and queer clients. These
include the assumption that sexual orientation is the cause of the present-
ing problem—such as when therapists try to connect presenting problems to
the clients’ sexuality, but clients disagree that there is a connection. At the
opposite pole, there may be avoidance and minimization of issues related to
sexual orientation, such as when therapists avoid using lesbian, gay, bisexual,
and queer terminology or change the topic when sexual orientation issues
are raised. Conducting qualitative research can allow humanist psycho-
therapists and researchers to engage their imaginations and become more
sensitive to their clients or to the diversity of experience that exists within
a topic under study.
DEVELOPMENT OF PRINCIPLES FOR PRACTICE:

QUALITATIVE RESEARCH FOR CLINICAL ENDS
Qualitative research methods can be ideal for the development of prin-

ciples to guide therapeutic practice because of their ability to capture both the
internal experience of the client and the intentionality of therapists. This sen-
sitivity to the subjective within an interpersonal context lends itself to iden-
tifying the pivotal moments in sessions that can transform the experience
of the client or the direction of the session by informing clinical decision
making. Instead of producing findings that identify either helpful or hin-
dering moments as such, this research is focused on identifying contextual
factors that can assist therapists in making choices about interventions and
enhancing their responsiveness. In response to calls for qualitative outcome
research (e.g., Daniel & McLeod, 2006) and initiatives in the field to develop
principles of psychotherapeutic change based on quantitative research find-
ings (Castonguay & Beutler, 2006), I have argued that the development of
principles to enhance attunement in practice is a desirable outcome for quali-
tative psychotherapy research (e.g., Levitt et al., 2006; Levitt, Neimeyer, &
Williams, 2005). I have also developed a program of qualitative research identi-
fying principles across psychotherapy orientations. Stiles (2015) described this
effort as enriching research, which is conducted for the purpose of deepening
the understanding and appreciation of a phenomenon. In this section, I pro-
vide an example of how qualitative research of this type can inform clinical
practice.

In contrast to previous research that had aggregated all silences together
as a homogeneous phenomenon (e.g., Berger, 2004), grounded theory research
on clients’ experiences in sessions allowed for the development of a typology
of silent processes (Levitt, 2001). These processes described relational and
processing dynamics that were so powerful that they stopped the flow of ses-
sion discourse. Although silences have long been thought to be signals of cli-
ents’ resistance, regression, and withdrawal (e.g., Fliess, 1949), Levitt (2001)
identified productive processes that unfolded within silence, such as the
experiencing of deep emotion, rapt self-reflection, and the struggle to develop
labels to describe previously inchoate experiences. These moments were in
contrast to negative moments of silence representing client disengagement or
concerns about the therapy process. The clinical principle derived from this
study was that therapists should actively encourage and structure productive
moments of silence but should also inquire about clients’ internal experiences
after moments of obstructive silences.
The brief vignette below from an emotion-focused psychotherapy ses-
sion provides an example of how therapists might structure moments of
productive silence. The client has been contemplating talking with her
father, from whom she has been emotionally distant, about their relation-
ship. Although the client has long known that her father mistreated her,
she has just realized in therapy that the mistreatment was due to his general
state of disconnection from her and others in his life rather than from the
malicious intentions with which she had credited him previously. Silences
and their duration are indicated to aid in the reading. (e.g., p:03 indicates a
3-second pause).
Client: Like, how do I plan my moment [to] say something a little
deeper or probe a little bit without immediately [stopping] . . .
like, I couldn’t put my cards on the table and say I’ve been
to therapy and this issue keeps coming up and I need to—I
need to get feedback.
Therapist: So, so it’s too big.
Client: Like, I couldn’t do it like that. I think it would—it would
upset him.
Therapist: You know, I’m also aware, before we started, you’re sort of
saying this thing of, “OK, I realized this thing about my
relationship with my father, but now what do I do with it?”
Right. I’m wondering, and you said, you know, and you’ve
told me a whole number of things about what’s going on.
But I’m wondering if you could take some time now and go
inside. See . . . you know, there’s all of this now to bring up.
102 heidi m. levitt

You don’t know how to handle him in the actual meeting,
but let’s go inside and see. Of all of these things, and of all
the complexity, right, what right now seems most salient for
you, what’s most important, and I don’t quite, you know,
what [p:03], if you go to that place inside where you feel your
feelings [p:04]—even if you ask yourself, what of all of these
things right now is most alive for me, most [p:04] important
[p:03]—all included as . . . [Note: Within this disjointed dia-
logue that explicitly encourages the client to hold an introspective
gaze, the therapist is beautifully structuring multiple pauses that
model introspection. The pauses permit the client to come into
contact with her emotions and, from that contact, begin to iden-
tify her sadness and make sense of it.]
Client: If I, if I stop enough, I feel upwellings of sadness, about . . .
it’s kind of, “How could I have been so mistaken, been so
convinced that I could control his moods, and it was my
fault?” I feel I need to go through all these things again, and
picture it as though he didn’t know I was in agony, he didn’t
know I was afraid. He didn’t know. He shut out the world
around him ‘cause he had his own little things he was in a
tizzy about, and I was an innocent bystander.
Therapist: Yeah, yeah, so there’s a sadness, the sadness. [p:10] [Note:
Again, the therapist directs the client’s attention internally and
then allows a long pause so the client can come into contact with
this feeling as the process of meaning-making continues.]
In this moment, it is striking how the therapist has acted to enable numerous
moments of silent introspection in close proximity. His pauses were timed to
fall within the phrases of his sentences, preventing the client from answering
prematurely. The repetition in his phrasing around the pauses functioned
beautifully to hold the client’s attention fast on the question being put to
her—what is most important to her, right now, to communicate? While these
silences prolonged her engagement with this question, he explicitly directed
her to introspect time and again, providing spaces in the silences for her to do
so. The effectiveness of this introspective process is signaled by her response,
“If I stop enough, I feel . . .” In the research interview after a review of the
recorded session, the client reflected on her experience of the pauses through
this sequence.
I found that moment very difficult. We’ve done that before, a couple of
times, when I feel a tension in my chest. I find it very touching—like,
“What ails you?” I’ve always found that very profound. At that moment,
I was thinking, I can’t do it. I don’t know the answer. I’m supposed to

give him [the therapist] something right now, what is it? And I feel this,
I don’t know, I feel this, I don’t know, I’ve had this before where I’ve
slowed down, and I feel a compassion toward myself, and it brings up very
sad feelings. But I also find it very uncomfortable. I tend to avoid focus-
ing in . . . I’m, I’m never sure, how close, like there’s definitely a feeling
of welling here, and I’m sad, but if I waited another 5 minutes maybe it
would change? . . . Did I really do what he [the therapist] asked? Did I
take the time, did I? Should I take more time? . . . There’s uncertainty,
but I’m also feeling touched. . . . Even with myself, I’m uncomfortable
with it, it makes me tearful . . . but it does put me back in touch with my
compassion for myself.
The client used these moments of silence to experience mourning for
her childhood injuries and self-compassion. This contact with her emotions
assisted her in identifying the aspects of her insights in therapy that were
most important to her and that she might want to share with her father.
Yet we can see that she might have benefited from an even longer period of
silence to come to terms with her feelings and develop more confidence in
her experience.
The clinical implications from this body of research on silence include
the differentiation of productive from obstructive silences and guidance on
how to respond to each type. The example provided demonstrates how ther-
apists might model, actively structure, and encourage clients to engage in
and maintain productive silences. In contrast, obstructive moments of awk-
ward silence in sessions when clients seem confused, withdrawn, or shut off
might best be dealt with by directly asking clients a variation of the question
“What is happening inside of you right now?” Because moments of silence
are often reported by novice therapists as some of the most challenging times
in therapy, it can be helpful to have principles to guide therapists to develop
responses in the uncertainty that these moments can generate. Qualitative
research that aims to develop principles for practice is geared toward helping
therapists make differentiations that can increase their attunement in ses-
sions and lead to more responsive interventions.
A recommendation for future humanistic psychotherapy research is to
continue to develop findings that can guide therapists in decision points with
their clients. The contextual focus of these principles would be appropri-
ate outcomes from either constructivist–interpretive or critical–ideological
frameworks (e.g., Levitt, Neimeyer, & Williams, 2005). In particular, focus-
ing on how to resolve therapeutic tasks (e.g., Greenberg, 2007), reconcile dif-
ferences within clients’ reported experiences, and identify expert therapists’
intentions (e.g., Goldfried, Raue, & Castonguay, 1998; Jennings, Sovereign,
Bottorff, Mussell, & Vye, 2005; Levitt & Williams, 2010) could generate use-
ful guidelines for clinicians.
104 heidi m. levitt

This chapter has outlined the major traditions of qualitative psycho-

therapy research used by humanistic psychologists, focusing on the inter-
connection between humanistic and qualitative research philosophies. In
addition, I have presented findings from reviews of the literature base that
have described key components of humanistic therapies as well as common
factors that appear to hold central places in the process of change. These
findings emphasize the power of the therapeutic relationship and the place
of empathy, emotion, and vulnerability within psychotherapies of all types.
Therapists can take from this body of research an affirmation of humanistic
principles such as the importance of clients feeling support from therapists,
developing a new view of the self in relationship to others, making contact
with the therapist, and developing a greater appreciation of their internal
experiences. Repeated cautions include the need to attend carefully to signs
of disengagement and deference in therapy through close attunement and
process assessments (e.g., “What is happening for you right now?”) to avoid
misunderstandings. The relative absence in this literature of discussion of
symptoms based on clients’ experiences in sessions is remarkable; instead,
clients’ assessment of their therapy appears to revolve around increased
understanding and the development of self-acceptance, within humanistic
and nonhumanistic therapies alike.
Humanistic researchers are at the forefront of developing standards to
assess qualitative research, while resisting the trend to do so in terms of rigid
sets of procedures. Qualitative research, rather, needs to be evaluated as a
set of methods to be creatively adapted to facilitate inquiry in relation to
the goals and characteristics of the study at hand (e.g., Elliott et al., 1999;
Levitt, 2015; Wertz, 2005). Although the proportion of humanistic research-
ers may be low, and the diversity of theoretical perspectives is decreasing in
academic clinical psychology (see the findings in Heatherington et al., 2012,
and Levy & Anderson, 2013, that document the disappearance of diversity in
therapy orientation within clinical psychology training programs), we have
an important role to play in shaping this discourse and mentoring new voices
in our field.
Qualitative researchers have come incredibly far in developing a rich
body of literature on the psychotherapy experience, and humanistic research-
ers have had a leading role in that effort that is deserving of recognition. We
need to move forward with developing approaches that honor not only the
methods we select but also our goals as they interact with ourselves, our phe-
nomena, and our participants. And, also important, we can look within each
individual study for coherence in the quest for innovation and continue to
develop findings that enrich the practice of psychotherapy.

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4
THE ROLE OF EMPATHY IN
PSYCHOTHERAPY: THEORY,
RESEARCH, AND PRACTICE
JEANNE C. WATSON
Research has consistently demonstrated that therapist empathy is one

of the most potent predictors of client progress in psychotherapy across every
therapeutic modality (Constantino et al., 2008; Elliott, Bohart, Watson, &
Greenberg, 2011; Norcross & Lambert, 2011a, 2011b; Norcross & Wampold,
2011; Sandage & Worthington, 2010; Watson & Watson, 2010). However,
although empathy is seen as the bedrock of psychotherapy, its power is often
underestimated and not well understood. There are numerous working defi-
nitions of empathy, including those from developmental science and social
psychology, as well as from the psychotherapy literature (Gibbons, 2011;
Singer, 2006; Watson, 2007).
Rogers (1951/1965) defined empathy as the ability to perceive accu-
rately the internal frames of reference of others. His definition highlights
empathy as both an emotional and a cognitive process. He saw empathy
http://dx.doi.org/10.1037/14775-005
S. Rubin (Editors)
115
as the ability to see the world through others’ eyes so as to sense their
hurt and pain and to perceive the source of their feelings in the same way
as they do. In this regard, he was careful to distinguish identification from
empathy, seeing the former as indicating a loss of boundaries otherwise
conceptualized as emotional contagion. Rogers (1959, 1975) and Kohut
(1971, 1977) used the term to describe a way of being with others to pro-
mote healing in psychotherapy. This usage drew on the meaning of the word
that emphasized the capacity to understand the experiences, thoughts, and
feelings of another.
Numerous theorists have seen empathy as a basic relationship skill that
is required to understand others at even the most basic level (Bohart &
Greenberg, 1997; Feshbach, 1997; Hoffman, 1982; Jordan, 1997; Linehan,
1997; Trop & Stolorow, 1997; Watson, Goldman, & Vanaerschot, 1998).
There are different levels of understanding and different types of empathic
process. We can understand others by knowing what they mean intellec-
tually, by comprehending their values, worldviews, goals, and objectives.
However, for a fuller understanding we need to know how people are affected
emotionally, because this reveals the significance or meaning of events
for them (Greenberg, Rice, & Elliott, 1993; Gross, 2007; Rogers, 1951/1965;
Taylor, 1985).
Barrett-Lennard (1993) posited a model of empathy as an active, cycli-
cal process characterized by three phases: empathic resonance, empathic
communication, and perceived or received empathy. In the first phase, thera-
pists resonate to their clients’ experiences using information from their own
bodily reactions and inner experience to understand how their clients are
feeling moment to moment and to understand the significance and mean-
ing of events for them. In the second phase, therapists communicate their
understanding to their clients, and in the third phase, clients apprehend and
receive their therapists’ empathy to feel understood (Watson, 2007).
Bohart and Greenberg (1997), in their review of empathy, differenti-
ated among three types of empathy: person, affective, and cognitive. Person
empathy is an understanding of the whole person in situ. It requires an under-
standing of what clients have experienced, including their histories and life
stories, to acquire a holistic understanding of who they are and how they
developed. Affective empathy refers to being attuned to the affective experi-
ence of others as revealed by their body language and narratives to under-
stand clearly the impact and significance of events for them. Cognitive empathy
is the capacity to understand and make sense of clients’ narratives. According
to neuroscientists, empathy is a “complex form of psychological inference that
enables us to understand the personal experiences of another person through
cognitive, evaluative and affective processes” (Danziger, Prkachin, & Willer,
2006, p. 2494).
116 jeanne c. watson

RESEARCH ON THE ROLE OF EMPATHY IN
PSYCHOTHERAPY BEFORE 2000
The role of empathy in facilitating change received considerable atten-

tion in the research literature, after Rogers (1957) posited that it was one of
the core therapist conditions necessary and sufficient for psychotherapeutic
change, together with unconditional positive regard and congruence. Early
research on empathy was criticized on a number of counts, including difficul-
ties defining the construct, poor research tools (Barkham & Shapiro, 1986;
Duan & Hill, 1996; Sexton & Whiston, 1994), and the observation that cor-
relations between external judges’ ratings and clients’ ratings of therapists’
empathy were low (Bozarth & Grace, 1970; Kiesler, Mathieu, & Klein, 1967)
or nonexistent (Burstein & Carkhuff, 1968; Hill, 1974; Kurtz & Grummon,
1972). Another factor affecting the research on empathy was the increased
interest in the concept of the working alliance (Duan & Hill, 1996; Orlinsky,
Grawe, & Parks, 1994).
Numerous studies conducted before 2000 tried to determine whether
empathy was a necessary and sufficient condition for successful outcomes
in psychotherapy. Overall, the early evidence provided support for the view
that therapist empathy is a crucial variable (Bergin, 1966; Gurman, 1977;
Patterson, 1984; Luborsky, Crits-Christoph, Mintz, & Auerbach, 1988;
Orlinsky et al., 1994). In their review of psychotherapy process and outcome
research, Orlinsky et al. (1994) noted that, in the period from 1972 to 1989,
54% of studies using either external or client-judged ratings of empathy sup-
ported the relationship between therapists’ communicating empathically with
their clients and therapy outcome. Luborsky et al. (1988), in their meta-analysis
of the efficacy of empathy, reported a mean correlation of .26 between thera-
pist empathy and client improvement. However, some researchers have also
found that clients’ perceptions of empathy varied over time, as did therapists’
understanding of their clients (Cartwright & Lerner, 1963; Kalfas, 1974, as
cited in Orlinsky & Howard, 1986; Kurtz & Grummon, 1972; Marangoni,
Garcia, Ickes, & Teng, 1995; Patterson, 1984). Qualitative studies in which
in-depth interviews with clients were conducted to determine the effective
elements of treatment found that one of the most important factors was the
opportunity to talk with an understanding, warm, and involved person (Cross,
Sheehan, & Khan, 1982; Feifel & Eells, 1963; Lietaer, 1990; Strupp, Fox, &
Lessler, 1969; Watson & Rennie, 1994).
Other studies investigated the behavioral correlates of empathy (Barkham
& Shapiro, 1986; Barrington, 1961; D’Augelli, 1974; Gardner, 1971; Tepper,
1973; Truax, 1970; Westerman, Tanaka, Frankel, & Kahn, 1986), including
therapists’ nonverbal behaviors, speech characteristics, response modes,
and personal characteristics. A relationship between therapists’ nonverbal
the role of empathy in psychotherapy 117

behaviors and perceptions of empathy was found, including direct eye contact,
concerned facial expressions, a forward trunk lean, and head nods (D’Augelli,
1974; Tepper, 1973). Therapists’ rates of speech, vocal tone, and clarity of
expression were also found to influence perceptions of empathy (Barrington,
1961; Bohart & Greenberg, 1997; Caracena & Vicory, 1969; Rice, 1965;
Tepper, 1973). Also important, therapist interruptions of the client were seen
as indicating less empathy (Pierce, 1971; Pierce & Mosher, 1967), and success-
ful clients spoke more often and for longer than less successful clients. This
latter finding was significantly related to therapists’ being rated as empathic
and warm in the session (Barrington, 1961; Staples, Sloane, Whipple, Cristol,
& Yorkston, 1976; Westerman et al., 1986).
Other therapist responses found to be related to clients’ perceptions
of their therapists’ level of empathic understanding include therapists’ use
of emotional words and exploratory responses and statements by therapists
expressing understanding, attentive listening, and receptive openness to the
client’s perspective (Barkham & Shapiro, 1986; Barrington, 1961; Henry,
Schacht, & Strupp, 1986; Watson, Enright, Kalogerakos, & Greenberg,
1998). In contrast, critical, hostile, and controlling statements were nega-
tively associated with successful outcomes in psychotherapy (Henry et al.,
1986; Lorr, 1965; Watson, Enright, et al., 1998). Therapists’ personal quali-
ties that were found to be related to empathy include being nondogmatic,
self-confident, open, curious, and nonjudgmental and perceived as being
similar to the client (Feshbach & Roe, 1968; Orlinsky & Howard, 1986;
Nerdrum, 1997; Tosi, 1970).
REVIEW OF RESEARCH SINCE 2000
The evidence for the positive impact of therapist empathy is among the
highest and strongest of all factors in the psychotherapy literature, and it con-
tinues to accumulate (Elliott, Watson, Bohart, & Greenberg, 2012; Lambert &
Barley, 2001; Norcross & Lambert, 2011a, 2011b; Watson & Watson, 2010).
Although an earlier meta-analytic study suggested that empathy might be more
important in cognitive–behavioral therapy than in humanistic psychotherapy
(Bohart, Elliott, Greenberg, & Watson, 2002), a more recent update has shown
that empathy is predictive of outcome across different psychotherapies (Elliott
et al., 2011). Empathy was found to have a medium or moderate effect size,
accounting for approximately 10% of the variance in outcome. This is more
than that attributed to the impact of therapeutic interventions (Elliott et al.,
2011; Wampold, 2001).
Spurred by Norcross’s (2001) observation that insufficient attention has
been paid to understanding what changes in psychotherapy as a function of the

relationship conditions, Watson and colleagues investigated the role of empa-
thy in the change process in cognitive–behavioral psychotherapy and emotion-
focused psychotherapy. Watson and Geller (2005) examined the relationships
among clients’ ratings of the relationship conditions, using the Barrett-Lennard
Relationship Inventory (Barrett-Lennard, 1962), the psychotherapy outcome,
and the working alliance in cognitive–behavioral psychotherapy and emotion-
focused psychotherapy with the process–experiential approach, with a sample
of depressed clients. Empathy as measured by the Barrett-Lennard Relationship
Inventory correlated moderately with clients’ self-report measures of the work-
ing alliance. Moreover, clients’ ratings of the relationship conditions, includ-
ing empathy, were predictive of treatment outcome for depression (Beck,
Ward, Mendelson, Mock, & Erbaugh, 1961), self-esteem (Rosenberg, 1965),
clients’ reports of interpersonal problems (Horowitz, Rosenberg, Baer, Ureño,
& Villaseñor, 1988), and dysfunctional attitudes (Weissman & Beck, 1978).
An interesting finding from this study was that the impact of the relation-
ship conditions on outcome was mediated through the therapeutic alliance on
three out of four outcome measures, which suggests that empathy is essential
to facilitating the development of a positive working alliance, including the
development of a positive bond and agreement on the tasks and goals of psy-
chotherapy. There were no differences between cognitive–behavioral therapy
and emotion-focused psychotherapists in terms of clients’ ratings of therapists’
empathy (Watson & Watson, 2010).
Building on Barrett-Lennard’s 1997 hypothesis that therapist empathy
leads to increased self-empathy, Watson, Steckley, and McMullen (2013)
examined whether clients who were treated for major depression with either
cognitive–behavioral therapy or emotion-focused psychotherapy with the
process–experiential approach showed changes in attachment style and self-
acceptance at the end of therapy. They found that clients’ ratings of thera-
pists’ empathy predicted changes in clients’ attachment styles, such as being
less insecure and more self-accepting and protective of themselves at the
termination of psychotherapy, and that these changes were associated with
positive outcome. The model accounted for moderate to large amounts of
variance (42%–70%) in outcome.
Watson et al. (2013) found a significant direct relationship between
therapists’ empathy and the outcome at the end of psychotherapy, as well
as a significant indirect effect showing that therapists’ empathy was associ-
ated with significant improvement in clients’ reports of attachment insecu-
rity and significant decreases in negative ways of treating the self, including
self-critical behaviors, silencing, and neglect at the end of therapy as well
as reductions on the Beck Depression Inventory, Inventory of Interpersonal
Problems, Dysfunctional Attitudes Scale, and Rosenberg Self-Esteem Scale
(Watson et al., 2013). Subsequently, Watson and Prosser (2007) investigated

the relationship among empathy, affect regulation, and outcome as posited
by Watson (2002, 2007), using path analysis. In this study, it was found that
the effect of therapist empathy on outcome was mediated by changes in cli-
ents’ affect regulation (Prosser & Watson, 2007; Watson & Prosser, 2007).
Overall, these more recent studies have provided further support for the role
of the clients’ experience of the therapeutic relationship in promoting posi-
tive outcomes in psychotherapy.
Evidence is accumulating for the role of empathy and empathic respond-
ing in studies investigating the efficacy of motivational interviewing. Woodin,
Sotskova, and O’Leary (2012) found that a higher ratio of reflective responses
to questions resulted in a greater reduction of aggressive behaviors among
men and women treated for partner violence. The use of open-ended ques-
tions was more effective in reducing violent behavior with women than with
men. Moyers and Miller (2013) reported that empathy is highly predictive of
outcome in the treatment of alcohol disorders and addictions more generally.
In contrast to empathic responses, they noted that authoritarian confrontation
or challenge led to poor outcomes and, in some cases, the worsening of patients’
conditions after treatment (Boardman, Catley, Grobe, Little, & Ahluwalia,
2006; Miller & Rollnick, 2002; Moyers & Miller, 2013).
It has been suggested that empathy lowers resistance, so that people who
are being treated for alcohol disorders are more likely to become engaged and
remain in treatment when responded to empathically (Miller & Rollnick,
2002; Moyers & Miller, 2013; Moyers, Miller, & Hendrickson, 2005). The
continued importance of the ratio of empathic to other types of responses in
facilitating treatment in motivational interviewing is clearly acknowledged,
with the criterion for the attainment of an expert level of practice defined
as a ratio of two reflections to one question (Angus & Kagan, 2009; Woodin
et al., 2012).
The important role of being nondefensive and transparent has been sup-
ported by several other studies, including the growing research literature on
resolving ruptures in the therapeutic alliance. Wolff and Hayes (2009) found
that clients viewed their therapists as less effective if they had negative reac-
tions to them. Negative reactions also affected ratings of the working alliance
and therapist empathy. Clients whose therapists had negative reactions rated
their therapist’s level of empathy and the working alliance lower than cli-
ents whose therapists did not have negative reactions. These findings point to
the consistent overlap among the four core relationship conditions specified
by Rogers (1957). Elliott et al. (2011) noted that empathy, congruence, and
positive regard are highly intercorrelated. Although some evidence exists that
they are independent constructs, there is also strong evidence that they are
intertwined, so that it may be better to think about them as an overall way of
being in relationship.

Examinations of Rogers’s interactions with clients have shown that
the majority of his responses focused on clients’ actions and cognitions as
opposed to their feelings (Brodley & Brody, 1990). Studies have shown that
a number of behaviors, both verbal and nonverbal, can contribute to clients’
feeling empathically understood (Elliott, 1986). Bachelor (1988) found that
clients experienced therapists’ cognitive and affective understanding of their
problems as well as their self-disclosing and nurturing behaviors as empathic.
Consistent with the earlier studies, Riess (2011) noted that other health pro-
fessionals are becoming more aware of the importance of empathy. She iden-
tified seven biomarkers of empathy, namely, eye contact, muscles, posture,
affect, tone of voice, hearing, and therapists’ responses. This is consistent with
earlier work that identified the behavioral correlates of empathy as including
eye contact, warmth, forward trunk lean, and vocal quality (Watson, 2002).
More recently, Dowell and Berman (2013) found that therapist forward trunk
lean was perceived as more empathic in constructivist psychotherapy than
in cognitive–behavioral psychotherapy. Thus, different behaviors may have
different meanings in different therapeutic approaches.
To capture the multidimensional nature of therapist empathy, Watson and
Prosser (2002) tested a new measure of expressed empathy. This is an observer-
rated measure that rates 5-minute videotaped segments of client and therapist
interactions on the dimensions of therapist vocal quality, facial expression, and
posture, as well as content. In preliminary work, the measure has been found
to correlate moderately with the Barrett-Lennard Relationship Inventory. A
recent factor analysis identified two factors, one that captures the nonverbal
aspects of therapist empathy and another that captures therapists’ comprehen-
sion of the meaning of clients’ utterances.
The capacity to understand another’s experience requires the listener to
be receptive and responsive to what is being communicated both verbally and
nonverbally. Barrett-Lennard (1997) called the capacity to attune to another’s
experience resonance. Empathic resonance means being attuned cognitively to
the meanings of clients’ narratives as well as their intentions, as they relate,
explore, and examine their experience. Therapist resonance refers to the capac-
ity to understand others’ affective states so as to fully comprehend the mean-
ing and significance of events for them and to understand how they modulate
and express their affect both interpersonally and intrapersonally.
A growing body of research in neuroscience has begun to illuminate
the physiological correlates of empathic attunement and resonance (Watson,
2007; Watson & Greenberg, 2009). The discovery of mirror neurons revealed
some of the physiological correlates that are activated when the physical and
emotional states of others are represented in another. The activation of mir-
ror neurons allows us to know what others are feeling and infer their inten-
tions, goals, and objectives. Although mirror neurons help to create a shared

representation of another’s state in one’s body, people are able to preserve
the “as-if” condition in the parts of the brain that distinguish self from other
(Decety & Jackson, 2004).
Since the discovery of mirror neurons, researchers have begun to describe
the neuronal architecture as well as the specific neural circuits in the brain that
are activated and associated with empathic processes. Several factors have been
identified as important with respect to mirror neurons and empathy (Watson &
Greenberg, 2009). First, mirror neurons fire when members of the same species
engage in goal-directed actions (Ferrari, Gallese, Rizzolatti, & Fogassi, 2003).
In this way, it is suggested that humans are able to understand the intentions
of others. Second, when people empathize with others, aspects of others’
experience are represented physiologically in people’s own bodies (Preston
& de Waal, 2002; Singer et al., 2004), thereby providing information that
enables one to imitate their actions and subjective states. Third, people rely
on contextual information to interpret and understand the actions of others.
Fourth, people differ in their capacity to empathize, and fifth, there are dif-
ferences in the evoked potentials of mirror neurons, depending on whether
the action is observed, imagined, visualized, or heard.
Mirror neurons that fire in response to goal-directed behavior alert peo-
ple to the intentions of others. This facilitates mutual coordination. As people
infer the intentions of others, they can coordinate their interactions. Research
studies have shown that mirror neurons fire when people watch others per-
form different actions (Ferrari et al., 2003; Iacoboni, 2007; Iacoboni et al.,
2005). However, this neuronal activity is now recognized to occur when par-
ticipants see others experiencing pain, hearing sounds, touching, and perform-
ing actions (Rankin et al., 2006). Some theorists have proposed that mirror
neurons provide the neural substrate for people to develop theories of mind to
the extent that they can infer others’ intentions and feeling states.
In addition to mirror neurons firing at goal-directed actions, researchers
have shown that participants respond to the emotional states of others (Watson
& Greenberg, 2009); thus, empathy can occur independently of motor network
activation (de Vignemont & Singer, 2006). There are distinct neural networks
that create shared representations of the states of self and others (Decety &
Ickes, 2009). Studies have shown that participants are able to simulate aspects
of others’ experience to understand their subjective states. The representation
of body states enables people to infer and feel what others are experiencing.
Facial expressions and postures associated with different feeling states are par-
ticularly salient; they activate areas of the brain involved in feeling emotion.
When facial expressions of emotion are seen, brain regions associated with
feeling that same emotion are activated. However, only parts of the experi-
ence are simulated—for example, researchers investigating pain have found
that, when participants observe others in pain, only those areas of the brain

involved in processing the emotional content are activated, as opposed to those
that actually register the experience of pain (Preston & de Waal, 2002; Singer
et al., 2004).
Neural circuits are selectively activated depending on context (Iacoboni,
2007; Iacoboni et al., 2005; Wilson & Knoblich, 2005). In one study, the mir-
ror neurons of participants who saw three different scenes depicting a teacup
fired differentially. In the first scene, the teacup was on a table next to a teapot
and a plate of cookies; in the second, the teacup was on a table that was messy
with scattered cookie crumbs; and in the third, the teacup was alone without
any other additional information. The participants’ neurons fired most strongly
when viewing the picture of the teacup and the cookies yet to be consumed,
less strongly when viewing the picture of the messy table, and least strongly
to the picture of the teacup alone. This finding suggests that the context in
which events occur is important to the activation of mirror neurons, along
with people’s capacity to empathize with others (Watson & Greenberg, 2009).
These findings provide support for person empathy, advanced by Bohart
and Greenberg (1997). According to these theorists, therapists need to have
some sense of their clients’ history and the conditions in which they are liv-
ing to be able to empathize with their actions and feelings. Clients’ narratives
provide the scaffolding for therapists to understand their emotional reactions
and their frameworks for interpreting experience (Angus & Greenberg, 2011;
Watson, Goldman, & Greenberg, 2007). Without an understanding of clients’
histories and the significant events in their lives, it may be difficult to under-
stand why they are behaving as they are or to develop an adequate understand-
ing of their implicit emotion schemes. Moreover, the development of coherent
narratives can be helpful for clients, so that they too can better understand
the impact of their experiences and how these might have contributed to their
current behavior and emotions that they experience as problematic.
Mirror neurons are activated when participants observe others’ actions,
listen to stories, and visualize or imagine various scenarios (Danziger et al.,
2006; Decety & Jackson, 2004). However, there are differences in the evoked
potential of the activation depending on the modality. Emotion that is gener-
ated watching a movie and that which is generated by means of recollection
have symmetrical increases in activation (Watson, 2007). In contrast, imag-
ining scenes has a lower evoked potential than observing the same scenes
(Decety & Jackson, 2004). The capacity to empathize is augmented in expe-
riential psychotherapy, because therapists work with clients to activate vivid
recollections of experience to process them. The more vividly clients are able
to describe events, the more likely it is that they will access their feelings
and that their therapists will be able to visualize them too, thereby enhanc-
ing their empathic capacity in the session (Watson, 1996). Moreover, there
are differences in the rate of neuronal firing among individuals, with those

who score high on empathy showing a higher activation of mirror neurons
than those who do not score as high (Gazzola, Aziz-Zadeh, & Keysers, 2006).
These findings suggest that people may differ in their capacity to be empathic.
Greenberg and Rushanski-Rosenberg (2002) investigated therapists’ sub-
jective experience of empathy in the session, finding that, when therapists were
trying to be empathic, they were actively engaged as they tried to understand
their clients’ stories, imagine the events clients were recounting, sense their
clients’ experiences by attending to their body language, feel their clients’
experiences using their own reactions, reflect on their clients’ experiences,
and draw on their own experience to understand their clients’ experiences.
Therapists in this study spoke about working to distill the essence of what
clients were saying. They attended to clients’ body language and posture as
well as to their vocal quality and facial expressions to try to understand fully
what their clients were experiencing in the moment. They reported that they
drew on other experiences or reflected on their clients’ stories to infer what
they were experiencing in different situations. Some therapists spoke about
playing movies in their heads as their clients recounted events; others evoked
images to try to visualize what was going on. They also drew on their own
store of memories to feel their way into clients’ narratives.
In addition to these strategies, therapists reported that they paid atten-
tion to their own physiological responses. Some therapists noted that they
would experience bodily reactions to their clients’ reports of pain. In attempt-
ing to be empathic, they would attend to the feeling of sadness or slight sense
of fear that they experienced in response to clients’ narratives (Watson, 2007).
However, supporting the findings from neuroscience, the therapists were
keenly aware that their feelings were muted, being experienced by their clients
and not themselves. They also experienced complementary feelings of com-
passion, care, and acceptance of their clients’ experiences. Many of these pro-
cesses seemed to happen automatically, out of conscious control (Greenberg
& Rushanski-Rosenberg, 2002; Watson, 2007).
Building on research investigating the physiological impacts of mother–
infant synchrony, researchers have investigated the relationship between
empathy and client and therapist concordance in psychotherapy. The mutual
regulation model of mother–infant interaction shows that infants actively mod-
ulate their interaction with others. The participants’ mutual interaction leads to
increased coordination and the development of interaction patterns, including
signaling, synchrony, and attunement (Ham & Tronick, 2009). Applying this
model in psychotherapy, Marci, Ham, Moran, and Orr (2007), using fluctuation
in skin conductance as a measure of concordance during a session, found that it
was related to clients’ ratings of therapist empathy. Two-minute segments of the
highest ratings of concordance, compared with 2-minute segments of the low-
est ratings of concordance, were associated with positive and affirming therapist

statements. This research is highly suggestive of the role that empathy might
play in facilitating clients’ affect regulation during a session. Just as mothers
and infants interact to regulate their affect, so, too, clients and therapists learn
to coordinate their interactions to work together. In addition, it is likely that
the positive and coordinated interaction provides biofeedback to clients with
respect to the felt sense of positive social interactions on which they can draw
outside of therapy to guide their interactions with others.
A number of different types of empathic responses have been identified in

emotion-focused psychotherapy. These types include empathic understanding,
empathic affirmations, empathic evocation, empathic exploration, empathic
refocusing, and empathic conjectures (Elliott, Watson, Goldman, & Greenberg,
2004; Watson, 2002) and, more recently, empathic doubling.
Empathic understanding responses are simple responses that convey sim-
ple understanding of what the client has said. They may or may not focus on
clients’ affective experience. For example,
Client: I am so tired . . . it is pointless to keep trying.
Therapist: So you are really tired and feel like giving up?
Empathic affirmations are responses intended to validate the client’s per-
spective. For example,
Client: I felt kind of put down when he tossed the project aside.
Therapist: Yeah, I get that it kind of made you feel small to have all your
hard work dismissed.
Empathic evocations are responses that are used to bring clients’ experi-
ences alive in the session, using rich, evocative, concrete, and connotative
language. For example,
Client: I feel confused . . . and not sure where to go from here.
Therapist: So it feels like you are lost and uncertain. You don’t have a
good sense of the road up ahead—like in a fog it is hard to
get a clear sense of direction?
Empathic exploration responses have a probing, tentative quality to exam-
ine the corners and hidden depths of clients’ experiences. For example,
Client: He sounded so scornful and superior.
Therapist: So there was just something about how he spoke to you that
made you shrink and feel . . . what . . . small?

Empathic conjectures are attempts by therapists to articulate that which
is implicit in clients’ narratives, especially with respect to how clients are
feeling or experiencing certain events. For example,
Client: When I was a kid, there was never anyone home after school.
Therapist: So what was that like for you? Was it lonely . . . sad?
Empathic refocusing responses, while staying within clients’ frames of ref-
erence, reveal an alternative perspective. For example,
Client: He never does any work!
Therapist: You sound angry—like he is malingering or something—it is
hard to see him as sick?
Empathic doubling responses are attempts to voice clients’ thoughts and
feelings as they share the impact of events and are working to try to express
them. They are particularly useful in empty chair exercises. For example:
Client: [Speaking to her father, an alcoholic, in an empty-chair dialogue.]
You were always out at the pub or sleeping off some drunken
binge.
Therapist: What was that like for you? Did you feel neglected?
Client: Yeah, yeah!
Therapist: So . . . I felt neglected and deserted. You didn’t care what
happened to me . . . I was so lonely. . . . [Client begins to weep
softly.] Can you say that to him?
To be perceived as empathic, therapists need to be warm, receptive,
involved, attentive, concerned, and responsively attuned to their clients.
Moreover, it is helpful if their vocal quality is natural, soft, and tentative
(Bernholtz & Watson, 2011). Distorted therapist vocal quality characterized
by marked pitch variation and a singsong element has been found to be related
to poor outcome in psychotherapy (Bernholtz & Watson, 2011; Rice, 1965).
Clarity of expression is also important. Disorganized speech can be confusing;
it may convey incongruence to the receiver. The more clearly a message is
communicated, the more understood clients feel (Bohart & Greenberg, 1997).
Specific types of therapist response modes are related to clients’ perceptions
of their therapists’ level of empathic understanding. An increased number of
emotional words and exploratory responses, especially of clients’ feelings, are
experienced as more empathic than general advice.
Truly empathic therapists understand their clients’ goals for therapy
overall, as well as moment to moment in the session, as they try to grasp the
live edges of clients’ narratives. The primary task is to illuminate the nuances
and inflections of what people say, reflecting them back to them for their

consideration. However, because clients express themselves on multiple lev-
els, therapists can choose to focus on their clients’ feelings, their perceptions
and constructs, their values, their assumptions, other people, and situations.
Experiential therapists continually engage in process diagnoses to determine
the focus of their empathic responses from one moment to the next. This task
is easier when clients are actively exploring their experiences and provide
live descriptions of situations and events, because this helps cue therapists to
what is significant and relevant in clients’ lives. The task of listening empathi-
cally is more difficult when clients describe their experiences in ways that are
detached and analytical. To shift the quality of clients’ engagement, therapists
can try to use metaphors to make clients’ experiences more vivid and ask cli-
ents to be more concrete in their descriptions to try to help them access their
autobiographical memories and inner subjective experience (Elliott et al.,
2004; McMullen & Watson, 2011).
Another way in which therapists can assist clients to symbolize their expe-
riences and track their emotional responses is to attend to that which is not said
or that which is at the periphery of clients’ experiences. For example, when
clients are very rational and analytical, it may be important to try to represent
empathically their emotional reactions by using emotion words or sharing the
therapist’s inner reaction. Alternatively, when clients are being very emo-
tional, it may be important to have them fill in the details of their situation,
to help them become more grounded and provide a clearer picture of what
is happening. Therapists can use their own physical responses to guide their
empathic responses, including their feelings, images, memories, or moments
when they resonate to the poignancy of clients’ stories. For example, if thera-
pists experience a feeling either similar to the client’s or complementary to it,
such as protectiveness or concern at a client’s pain, this may be a cue to respond
empathically in the moment. In addition, therapists can attend to their own
reactions to clients’ statements and behaviors in the session to provide guid-
ance as to how to intervene differentially.
Several different markers have been identified to guide therapists in
responding empathically in a differentiated way. The markers, or client state-
ments, include expressions of feelings, analytical descriptions, intense emo-
tions, evaluations and assumptions, and ruptures in the relationship.
The expression of immediately experienced feelings in the session is
often apparent when clients’ voices break, as when they are crying or express-
ing anger or fear (Rice, Koke, Greenberg, & Wagstaff, 1979). Other signs that
are possible indicators that clients are in touch with their emotions include
moments when clients’ descriptions are intensely poignant or they use vivid,
idiosyncratic language. When clients are experiencing their feelings intensely,
it is important to be empathically affirming and validating of their experience.
At these times, it can be vital for therapists to help clients experience and

acknowledge their feelings before resuming exploration. Therapists may need
to slow down and take a little time before asking clients to differentiate their
feelings further or analyze them in more depth. This gives clients permission
to experience and express their pain, and it implicitly begins to articulate the
important task of attending to and processing their emotional experience.
Analytical descriptions of self and situations refer to times when clients
are describing themselves as though they were observing a third party. At these
points, their narratives are rehearsed, with a tight, seamless quality. Therapists
may feel blocked and uncertain as to how their clients are feeling. It can be use-
ful to ask clients to attend to their bodies and turn their attention inward, to try
to access their feelings and become aware of the impact of events. Alternatively,
therapists can use empathic explorations or empathic evocation responses.
Reports of intense reactions or repetitions of some aspect of experience
can indicate that clients need to process certain experiences or that certain
issues are problematic. To facilitate clients’ processing of these experiences
and emotions, therapists can respond with empathic understanding to their
clients’ feelings. After they have expressed understanding, then therapists
can try to facilitate clients’ exploration of their reactions using empathic
explorations, if clients agree. These latter responses are invitations to cli-
ents to identify the triggers of their reactions, so that they can be processed
more fully and completely. Similarly, if clients constantly talk about their
emotional reactions while leaving the details hazy, an empathic evocative
response might be useful to invite them to provide a clearer description
of their situations. This type of intervention can help to ground clients’
reactions in real events, so that they can identify and see their patterns of
responding and the triggers of their behavior, reexamining them to find new
ways of perceiving and acting.
Expressions of evaluations and assumptions are statements indicating
that clients are judgmental of themselves or others or that they have made
assumptions without considering alternatives. It may not be useful at these
times to respond with empathic understanding responses. Rather, it may be
more helpful to slow clients down and empathically explore with them their
assumptions or evaluations. At times such as these, therapists are trying to get
clients to articulate their perceptions and reactions to the events in their lives
so that they can reevaluate and reexamine them and come up with alternative
explanations.
Expressions of rupture in the relationship include moments when clients
refuse to perform or engage in certain activities in therapy or suddenly go blank,
fall silent, or change the subject. As therapists become attuned to the rhythm of
their session with each client, they can monitor the latency of clients’ responses.
Long delays between therapists’ statements and clients’ responses might be an
indication that something is wrong in the alliance (Westerman et al., 1986). In

the event that therapists feel a certain resistance or lack of responsiveness on
the part of their clients, they might disclose their perceptions and ask their
clients for feedback. At these times, it is very important for therapists to be
open and receptive to their clients’ feelings. Empathic understanding and
affirmation can help clients discuss openly any difficulties they are having in
the therapy and allow for ruptures and misunderstandings to be repaired. By
opening these discussions in a nondefensive manner, therapists create the
possibility for difficulties to be explored so that the tasks and goals of therapy
can be renegotiated. At these times, it is very important for therapists to be
nondefensive to help clients become aware of how they are feeling (Watson
& Greenberg, 1995, 1998). Empathy in emotion-focused psychotherapy is
illuminated more fully in the case study presented next.
A CASE STUDY
Alan was a man in his 60s who had a serious heart condition as well as
diabetes and high blood pressure. When he came to therapy, he was seeking
help with his depression. His doctor wanted to prescribe antidepressants, but
they caused an adverse reaction with the other medications that he was taking.
He wanted to try to find an alternative way to deal with his depression. In the
first few sessions, he disclosed that he felt burdened and experienced consider-
able strain in his marriage. His wife had been diagnosed with a mental disorder
20 years previously, and Alan had cared for her and their children without the
support of other family members, who lived far away. The couple had emigrated
from South America 26 years earlier and had raised three children, two daugh-
ters and a son. By the time Alan came to therapy, the children were grown up;
one was single and pursuing a career as a doctor, and the other two were stay-
at-home mothers with children.
Alan’s primary objectives since his wife became ill had been to ensure
their children’s well-being and protect them from their mother’s condition. He
wanted to make certain that they were not burdened by their mother’s illness.
He felt ashamed and was concerned that if his daughters’ husbands were
fully aware of their mother’s condition, it would compromise their marriages.
His wife suffered from fits of rage as well as depression and delusions. Alan
had resisted institutionalizing her, against the recommendations of doctors,
because he wanted to protect his family from the shame. However, his doc-
tor had recently expressed concern, telling him that if his blood pressure did
not decrease, he would need to do something drastic to protect his physical
well-being. Alan hoped that psychotherapy might help to alleviate some of
the strain that he was feeling and have a positive impact on his blood pressure
and heart condition.

Alan was seen for 16 weeks in a short-term emotion-focused psycho-
therapy. In Session 3, he described how trapped he felt, while his therapist
responded empathically using conjectures.
Therapist: If you’re staying, if you have to carry this burden, how are
you going to manage?
Client: That’s a difficult . . . that’s something I can’t work out. I can’t
come up with a solution somehow. And seeing my mother-in-
law did not help.
Therapist: What is happening inside of you right now?
Client: Well, what I thought that . . . after seeing her . . . was that
[crying]. . . . She had carried a family on her back, since the
’30s. She went through the war. . . . And now none of the
children can take care of her. . . . Her husband has turned
berserk. If she didn’t run away, according to her, I guess, she
may have ended up being physically hurt.
Therapist: Mmm hmm. . . . So what happens for you when you think
about your mother-in-law . . . do you kind of feel over-
whelmed?
Client: Yeah.
Therapist: Sad?
Client: Very sad, I don’t think I will end up like her, but . . . ah . . .
[crying]
Therapist: Mmm hmm. . . . Hang on. So am I right in understand-
ing that you seeing her struggle, at this point in her life, it
reminds you of you? I mean, this is the time in your life when
you wanted to . . . things to be good?
Client: Yeah, that’s right.
The client is aware that his mother-in-law has sacrificed her life, and
he feels sad realizing that this mirrors his life. He feels regretful that he may
not have the opportunity to pursue his dreams, that his life may be wasted.
The therapist reflects his distress and works with him to articulate and symbol-
ize his sadness and to identify the factors that are contributing to his depression.
In the next excerpt, the client labels his feelings of sadness and the sense of
being trapped:
Client: Now it seems there’s sadness over me. I can’t break through.
Therapist: What is the sadness about?
Client: Umm . . . mainly because I can’t move. . . .
Therapist: So you’re feeling trapped. . . .

Client: Yeah, and I saw my mother-in-law being trapped and not
rewarded. She was suffering for what she had done.
Therapist: So there is a sense you’re being kind of hemmed in, there is
no way out?
Client: Desperately.
Therapist: So you would like to find a way out?
Client: I would like to, yeah.
He went on to say that he had hoped that his wife’s illness would be
cured. He had focused on caring for her and the children and did not think
of the future that much. Now he feels that he is in a straitjacket. In Session 6,
the client begins to wonder how he came to be in the current situation. He
poses an experiential question about his way of interacting with other people
that has left him burdened with the care of his wife. As he explores their
early years together, he realizes that, soon after they met, she turned to him
for assistance in dealing with her family, and that set a pattern. In Session 7,
as he continued to explore his situation, the client reaffirmed how important
it was to him that he not burden his daughters or son to protect them from
their mother’s condition. He also realized how angry he was with his wife’s
behavior, although at the same time he had difficulty expressing his feelings
to make his concerns known. He was especially worried about her habit of
letting things boil over on the stove, for fear it would cause a fire. He also
began to recognize how tired he felt. After exploring these feelings further,
he resolved to take better care of his own needs. His therapist continued to
empathize, using evocative reflections:
Therapist: So it’s kind of like carrying a huge weight.
Client: Yeah, and maybe it’s time that I do something for myself.
Therapist: So you want to do something for yourself?
Client: Yeah! I want to rest.
Therapist: So you want to stop carrying the burden and set it down, so
you can rest?
Client: And, uh, maybe I’ll find something I like to do and try to rest.
Therapist: So “I need to rest, I’m so tired.”
Client: Yes, I need to regroup and do things that will benefit myself.
In Session 9, the client realized that he continued to get upset and had
difficulty accepting his wife’s condition. His therapist began to explore his
feelings using empathic exploration.

Therapist: So it sounds like there’s part of you that hasn’t accepted your
wife’s condition, right?
Client: Yeah, I can’t understand it.
Therapist: You don’t understand, and somehow it is hard to accept how
difficult she is?
Client: That’s right, that’s right.
Therapist: It’s hard for you to kind of just forget about it?
Client: Yes. . . .
Therapist: And that, that keeps making you upset.
The therapist asked the client how they could work together to support
him and try to find an alternative way to cope with his wife’s condition to
protect his health. She used empathic evocations and refocusing responses:
Therapist: How are we going to help you feel easier about the small
things? How can they stop bugging you? Because it’s killing
you, right?
Client: Yes, that is what the doctor says.
Therapist: For you to get upset every time the water boils over—it’s
boiling over on the stove, but it’s boiling over in here too.
Client: [Laughs] Yes.
Therapist: Because it’s sending your blood pressure up.
Client: That’s right.
Therapist: So it’s killing you, when you get so upset about that water.
It’s killing you to get so upset about the water running.
Client: Yeah, yeah, yeah, mm-hmm.
Therapist: So, you have to ask yourself, if it’s worth it for you, right?
Client: Maybe yeah, that’s right.
Therapist: A little mess is not as bad as your blood pressure exploding. . . .
Client: That’s right. I need someone to tell me, if you don’t, if you
don’t, if you can’t stand it, it’s going to kill you. [laughs] I don’t
know if it will work for me . . . it worked for [partner’s name]
maybe.
At the following session, the client reported that his blood pressure had
dropped. He had visited his doctor, who noted that it had moved back into
the normal range and was significantly lower. Alan was very glad and was
feeling much better, with fewer palpitations, moments of pain, or feelings of
dizziness. He attributed his improvement to the therapy, saying that it had

helped greatly for him to be able to share his burden and to have the therapist
listen attentively to his concerns and worries. Talking with her reminded him
of his chats with his mother and made him feel much better. He felt stronger
and more optimistic.
Subsequently, in Session 13, the client reported that, after exploring his
current situation and looking at his choices, he felt that he had done the right
thing in terms of caring for his wife and protecting his children. He felt less
regretful and more accepting. His therapist empathically reflected this change.
Client: Yeah, but I think it’s even more difficult to do what I had in
mind than I had imagined. I don’t even know if any of those
things I wanted to do would be, um, as good as I imagined
they would be.
Therapist: So how does that make you feel?
Client: I feel relieved.
Therapist: You feel relieved? Lightened?
Client: Yeah . . . I have some kind of acceptance, yeah.
In Session 15, the client observed that he had bottled up all his feelings,
not just his anger. He realized that he had carried his burdens alone and had
not shared his distress with anyone. As a result, he resolved to be more expres-
sive and share his feelings more.
Client: It was not just the anger . . . I think it is the all the emotions.
Therapist: So it was not just anger, but all your feelings?
Client: I think I have to be able to tell the person I am angry.
Therapist: Right.
Client: Yeah, or if I am happy, I should be able to say.
Therapist: So you are saying that you bottle all your feelings, you keep
a lid on all your feelings.
Client: I think that’s what the problem is, not just anger. Everything
else was bottled up.
Therapist: So you would like to be freer about expressing your feelings,
is that what you are saying?
Client: I think maybe that’s the way out of it. [laughter] The depres-
sion . . . that part of the burden I can maybe solve.
Therapist: So if you expressed your feelings more, you would not feel as
burdened?
Client: That’s right.

During the 16 weeks of therapy, Alan shared his grief at losing his mother,
with whom he had had a close relationship. She was the one person with
whom he had been able to share his concerns and worries. He missed her
and was sad that he had not been able to establish a similar relationship with
his wife. His therapist recognized that putting his needs first, ahead of those
of his family, was culturally unacceptable and at odds with his more family-
and community-oriented view, so she offered a primarily empathic, accepting
relationship. At the end of therapy, the client was no longer depressed and
maintained this status at 12- and 18-month follow-up; moreover, his health
continued to improve. He made new friends and reestablished contact with
friends with whom he had emigrated. He asked his children for assistance
with their mother so that he would have some free time to pursue some of
his interests. He made some travel plans and joined a group for families with
members who had severe mental health conditions. He wanted others to
benefit from sharing their concerns with supportive others. He no longer felt
ashamed and saw that sharing and talking with others about difficulties could
be very helpful. The use of a primarily empathic approach helped the client
shift to greater self-acceptance and to make significant changes in how he
processed and dealt with his emotions, even as he grieved his losses.
EMPATHY AS AN ACTIVE INGREDIENT OF CHANGE
Research on empathy has revealed that it is an essential component of

successful therapy across all modalities. Yet in most approaches, empathy is
viewed as an essential background condition that facilitates the implemen-
tation of the active interventions or change mechanisms. I would suggest,
however, that empathy is an active ingredient of change. Four important
functions of empathy have been identified: (a) interpersonal, (b) deconstruc-
tive, (c) facilitating affect regulation, and (d) facilitating the development of
positive introjects (Watson, 2002).
The Interpersonal Function of Empathy
Clients feel safe when they are listened to empathically. They feel heard,
understood, and supported. Safety in the relationship enables clients to focus
on their concerns within the therapeutic hour. It promotes exploration and
enables clients to examine and look at aspects of their experience that might
have been denied or relegated outside awareness. In addition to creating a
safe place, therapists’ empathy is important in forming and maintaining the
therapeutic alliance and in negotiating agreement on the tasks and goals of
therapy. Empathic therapists are able to monitor their interactions with their

clients and modify their responses if the latter are having difficulties engaging
in therapy. By being sensitive to the impact of their interventions on clients
and to the overall quality of the alliance, empathic therapists are alert to rup-
tures as well as moment-to-moment shifts in the relationship during a session
and over the course of therapy.
The Deconstructive Function of Empathy
Empathic responses help to deconstruct clients’ worldviews, constructs,

and assumptions about self and others, thereby highlighting the hermeneutic
aspects of empathy (Keil, 1996; Watson & Greenberg, 1998). Therapists are
seen as engaged in revealing their clients’ meanings and intentions, in the
same way as translators are charged with revealing the author’s intentions
in a text. Empathic responses assist clients to deconstruct their worldviews
and uncover the subjectivity of their perceptions, which helps them be more
hypothetical in their formulations of events, thereby providing them with an
increased range of action.
The Affect-Regulating Function of Empathy
Empathy helps clients to regulate their affect and learn to soothe them-
selves. Affect regulation is an important topic of investigation for social,
developmental, and neuropsychologists (DeSteno, Gross, & Kubzansky, 2013;
Feshbach, 1997; van der Kolk, 1994, 1996; van der Kolk, Roth, Pelcovitz,
Sunday, & Spinazzola, 2005). These researchers recognize the important role
that early attachment experiences play in people’s abilities to regulate their
emotions and their neurophysiological functioning. Clients who come to
therapy are often experiencing acute and chronic conditions related to dys-
regulation in their affective systems. Empathic responding begins to help
clients regulate their emotions, both within the session and in the long term.
Human beings experience a sense of relief and comfort when they feel
understood by another, especially when they are experiencing intense and
painful emotions. The expression and symbolization of emotions act to contain
and moderate them in the same way that rating them on a scale of 1 to 10 does.
Naming or labeling feelings begins the process of affect regulation. Once emo-
tions have been labeled, clients are able to reflect on them to understand the
impact of events and identify what they need to protect or nourish themselves.
The Strengthening of Self and the Development of Positive Introjects
As therapists listen to their clients, and attend to and accept their expe-
riences, they model positive ways of being with the self. Barrett-Lennard

(1997) referred to this as developing self-empathy. Empathic interactions build
positive, nurturing introjects and facilitate the development of positive ways
of responding to the self that are affirming, accepting, protective, and sooth-
ing. As these ways of treating the self develop, clients’ self-concepts change as
they become more self-accepting and less judgmental of themselves and their
experience and more self-confident (Barrett-Lennard, 1997; Bozarth, 2001;
Rogers, 1975; Watson, 2002).
Full empathic understanding of another develops over time. Novice
therapists tend to understand their clients intellectually, but not emotionally.
However, to understand another intellectually is to comprehend only the
surface meaning of what they are sharing, not the full significance of events
that guide their perceptions and reactions moment to moment. Full empathic
understanding grasps the range of meanings and feelings expressed by the other
as well as the implications and impact of events. Optimally, empathy enables
therapists to distill the essence of clients’ experiences. Empathy is vital to
the psychological and emotional development of human beings because it
enables one to forge connections with others and to understand them. In
therapy, it is one of the most powerful ways of being with clients to facilitate
healing and growth.
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5
EMOTION IN PSYCHOTHERAPY:
AN EXPERIENTIAL–HUMANISTIC
PERSPECTIVE
ANTONIO PASCUAL-LEONE, SANDRA PAIVIO,
AND SHAWN HARRINGTON
The idea that accessing and exploring painful emotions and bad feelings
in a therapeutic relationship may result in one feeling better in the long
term is now a widely held belief among several schools of psychotherapy,
but it has always been a central position among humanistic and experiential
therapists beginning with Rogers (1951) and Perls (1969). In this chapter,
we review process and outcome research on emotion in psychotherapy, with a
special focus on the theoretical framework and interventions of experiential
treatments.
Humanistic and experiential therapies have led the way in developing
interventions that address emotion directly in a manner that is sensitive to
personal development and idiosyncratic meaning. The recent emergence of
affective neuroscience has further stimulated interest in the role of emotion
in psychotherapy by providing a means to observe and measure affect in vivo.
Early work examining emotional experience included Rogers’s (1951) focus
http://dx.doi.org/10.1037/14775-006
S. Rubin (Editors)
147
on the importance of attending to and prizing a client’s internal frames of
reference, Gendlin’s (1964) articulation of how productive experience unfolds,
and Gendlin’s (1996) emphasis on affective expression, enactments, and evoc-
ative encounters.
Drawing on this foundation, Greenberg and others (Greenberg, 2002;
Greenberg & Pascual-Leone, 2006; Greenberg & Watson, 2005) have identi-
fied five distinct types of emotion processes that are useful in therapy, depend-
ing on a client’s presenting concern. They are (a) emotional awareness and
engagement; (b) arousal and enactment; (c) emotional regulation and self-
soothing; (d) reflection on emotion and meaning-making, which involves
enduring cognitive change; and (e) emotional transformation, or changing
emotion with emotion. Research findings are summarized below and illustrated
with brief examples of client process. We go on to highlight some of the practi-
cal implications of working with emotion from a humanistic and experiential
approach.
SUMMARY OF MAJOR EARLY LITERATURE TO 2000:

EMOTION AND EMOTIONAL PROCESSING
Since their inception, humanistic and experiential understandings of

emotion have assumed that, when emotion is authentically experienced and
expressed in an empathic and facilitative interpersonal context, it can be
adaptive. Although there are exceptions to this, research has supported the
role of emotion in adaptive functioning in at least six distinct ways.
Role of Emotion in Adaptive Functioning
First, the emotion system may serve as an adaptive orienting system.

Discrete, basic emotions are associated with specific motivational information.
For example, fear tells people that they are in danger and in need of protection
or safety. This tacit information entails specific neurological activity, expressive-
motor patterns, and dispositions for orientation to and readiness for action in
specific goal-directed behavior important for survival (Frijda, 1986).
Second, emotions are both motivators and states of readiness for action.
They help people to survive by providing an efficient, automatic way of
responding rapidly to important situations. To that end, affect is processed
faster and requires less mediation (fewer levels of processing) than cognition
(LeDoux, 1996). It has been demonstrated, for example, that emotion can
be activated with subliminal stimuli and inform behavior outside a partici-
pant’s awareness (Whalen et al., 1998). Moreover, emotional processing has
been shown to be essential for exercising good judgment and decision making
148 pascual-leone, paivio, and harrington

(Damasio, 1999). In short, cognitive goals are given impetus by the orienting
and action functions of affect.
Third, the salience of particular emotions provides important information
about one’s priorities. Negative emotional responses, such as anger or sadness,
signal and are related to the experience of specific unmet needs (Frijda, 1986).
The assumption here is that there is a basic need or drive for internal
coherence that compels maladaptive emotional processes to be resolved.
This assumption also underlies constructs such as cognitive dissonance
and narrative coherence. Simply put, individuals have a predisposition
to be internally coherent (J. Pascual-Leone, 1990; Pennebaker, 1997).
Positive, negative, adaptive, and maladaptive emotional experiences all
inform people about the degree of this coherence and the need to resolve
inconsistencies. Emotion is the impetus for the neural integration in the
brain that results in attention to priorities and movement toward coherence
(Schore, 2003).
Fourth, the ability to work with and express emotional experience is an
important part of emotional intelligence and healthy development (Goleman,
1995; Mayer & Salovey, 1997). Work in personality and social research has
highlighted the importance of emotional intelligence. Curiously, in the clini-
cal field, differences in emotional intelligence among clients are more often
described in terms of clinical change in emotional health rather than as a trait
per se. A series of studies have shown the positive effects that writing about
emotion has on autonomic nervous system activity, immune functioning, and
physical and emotional health (Pennebaker, 1997). Conversely, the inhibition
of emotional expression has been linked to poor health and impaired immune
system functioning (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002). Finally,
emotions are an interpersonal communication system telling others to draw
closer or back off. Experience and appropriate expression of emotion increase
the likelihood of getting interpersonal needs met.
Emotion as a Densely Packaged Unit of Information
Over the past 60 years, the humanistic emphasis on spontaneous and

emerging experience has described emotion as a chief source of personal infor-
mation. Rogers anticipated this in some of his early writings: “While . . . insight
appears simple enough, it is the fact that it comes to have emotional and opera-
tional meaning [italics added], which gives it its newness and vividness” (Rogers,
1951, p. 119). Gendlin (1964) further stated that it is through contact with,
and exploration of, feelings that new feelings and meanings emerge, resulting
in reduced client distress. This distinction between the felt and the known
(see also Damasio, 1999) is one that has been emphasized by all leading expe-
riential theorists.
emotion in psychotherapy 149

When Greenberg and Paivio (1997) applied the ideas of Frijda (1986) to
clinical work, they illustrated how emotion consists of a multimodal associa-
tive network of information or meaning system (see also Greenberg & Safran,
1987). For example, in session,
77 anger organizes one to fight and defend one’s boundaries;
77 fear organizes one sometimes to freeze and monitor, then run,
flee, and escape;
77 shame organizes one to hide oneself from the scrutiny of others;
77 sadness organizes one to seek comfort but later to withdraw and
conserve resources;
77 disgust organizes one to spit out or reject some noxious experience;
77 guilt organizes one to repair some situation; and
77 love, happiness, curiosity, and other positive emotions organize
one in different ways to reach out, build, share, celebrate, and
explore.
In earlier literature, the term emotion structure is most frequently used to
refer to this system (Foa & Kozak, 1986; Greenberg & Safran, 1987; Rachman,
1980). From this perspective, evocative experiences are encoded in emotion
structures centered on the experience of certain emotions. Current stimuli that
resemble the original emotional context (i.e., a trauma) can activate feelings
of fear and helplessness, associated somatic experiences, the desire to escape
the danger and avoid harm, and beliefs about self and the situations formed at
the time of the trauma. In this case, exposure procedures are intended to acti-
vate this fear structure so that maladaptive components are available for modi-
fication. Whatever the emotion in question, activation takes place through
attention to sensory and somatic aspects of memory.
Thus, to overcome emotion avoidance, clients must first be helped to
approach emotion by attending to their emotional experience. Fritz Perls and
Gestalt therapists were among the first to describe how to contact and acti-
vate emotions, which involved enactment, or expression of feelings toward
an imagined other or some part of the self (Yontef & Simkin, 1989), a pre-
cursor to techniques later used in emotion-focused therapy. For change to
occur, clients must also allow and tolerate being in live contact with aroused
emotions. These two steps are consistent with notions of exposure. Although
experiential and humanistic conceptualizations were arguably more nuanced
(see Greenberg & Paivio, 1997), behavioral therapy offered some of the first
palpable research findings about the importance of activating emotion. There
is a long line of evidence on the effectiveness of exposure to previously avoided
feelings. For example, in a series of studies on behavioral exposure (Foa, Riggs,
Massie, & Yarczower, 1995; Jaycox, Foa, & Morral, 1998) as a treatment for
posttraumatic stress disorder after rape, good outcome was predicted by the

aroused expression of fear while clients retold trauma memories during the first
exposure session and by the attenuation of distress during exposures over the
subsequent course of therapy.
Overwhelmingly, the early literature on humanistic and experiential
therapy underscores the importance of emotion in psychotherapy. In par-
ticular, this body of early research has pointed to emotion as an adaptive
network of meaning, rich with information that allows one to orient oneself
toward and prioritize problems while also motivating one to act to resolve the
problem. In doing so, clients must engage, instead of avoid, emotion and be
willing to accept emotional experience.
CURRENT RESEARCH ON EMOTIONAL PROCESSING:

EXAMINING CLIENT PROCESS
To consider how emotional processing is manifested in general, and in

experiential therapy in particular, one must accept that emotional processing
is not actually a singular phenomenon. In this section, we delineate a number
of different processes subsumed under the label of emotional processing, explor-
ing how they function in relation to one another. Doing so is imperative for
a deeper understanding of both what emotional change is and what expe-
riential therapies do to promote this process (Greenberg & Pascual-Leone,
2006). Greenberg (2002; Greenberg & Pascual-Leone, 2006) proposed the
notion of emotional processing subtypes. In a review of emotion research in
psychotherapy, his line of work identified several major ways to work produc-
tively with emotion.
Emotional Awareness and Engagement:

“Getting in Touch With What’s There”
Insight-oriented therapies are founded on the assumption that increas-

ing client awareness of emotional experience—usually the origins, meaning,
and consequences of maladaptive emotion—is an important change process.
Increasing awareness often requires a certain degree of arousal and immer-
sion into bad feelings and emotional pain while accepting this experience.
Again, this is fundamental to the effectiveness of exposure-based procedures.
This is also the assumption underlying posited change processes of emotional
insight, at the same time as challenging “hot cognitions” (Coombs, Coleman,
& Jones, 2002). Even though the importance of emotional awareness is
acknowledged by varying approaches to psychotherapy, emotions associated
with psychological distress are frequently suppressed or avoided, such that
clients feel flat or numb. In these instances, deliberately increasing arousal

is productive not for cathartic purposes, but rather to activate the emotion
structure and thereby increase awareness of the information associated with
emotional experience. However, the deliberate immersion into feeling bad
is difficult for clients and, when client arousal increases in session, therapists
who are not explicitly trained to engage affective arousal can also become
anxious and abandon the task. This, in turn, can be perceived by clients as
invalidating and can reinforce their avoidance.
Humanistic therapists facilitate client awareness; the more experiential
the therapist, the more he or she will also facilitate arousal, from the very begin-
ning of therapy. However, when clients become emotionally aroused and elab-
orate on their experience, there are various possible facets of that experience
(assertion, hurt, disgust, hopelessness, etc.) on which a therapist might choose
to focus. Moreover, not all facets of that experience have equal potential for
client progress. Thus, clinicians need to be selective about which experience
to emphasize to promote further processing (i.e., empathic selection and reflec-
tion; see Greenberg & Elliott, 1997).
Emotion awareness and engagement are not simply talking about emo-
tion, but also feeling it. This issue of how clients engage in emotion has been a
critical one. A key study on this topic (Paivio, Hall, Holowaty, Jellis, & Tran,
2001) showed that dosage (i.e., quality of process multiplied by frequency of
engagement) has been found to be the most predictive variable in terms of
outcome, rather than either quality or frequency of engagement alone (Paivio
et al., 2001). Thus, clients who are only minimally engaged during such emo-
tionally evocative tasks may need to be encouraged to participate in them
more frequently and fully to receive maximum benefit.
Another issue that presents itself in psychotherapy is that some clients
have marked difficulties in accessing and elaborating their emotional expe-
rience. The current conceptualization of alexithymia, which literally means
“no words for feelings,” is that it describes an individual’s limited capacity
to symbolize and elaborate emotional experience (Taylor & Bagby, 2013).
Despite this being an often-discussed construct in clinical literature, the
treatment research is sparse, although it does seem to suggest (contrary to
some clinical opinion) that a client’s level of alexithymia has little influence
on the treatment he or she may prefer. Nevertheless, it is associated with
poorer treatment outcomes in both psychodynamic and supportive therapies
(Ogrodniczuk, Piper, & Joyce, 2011). Interestingly, one outcome study using
emotion-focused therapy for relational trauma found a 68% decrease from
pre- to posttreatment in the number of participants who met the criteria for
alexithymia (Ralston, 2006, as cited in Paivio & Pascual-Leone, 2010); this
occurred despite the fact that the characteristic emotional shallowness of
alexithymia is commonly considered a personality trait (see Taylor & Bagby,
2013). One interpretation of this unique finding is that, because the aim

of an experiential therapy is to deepen experiencing (i.e., clients’ affective
awareness and symbolization), the observed reductions in alexithymia may
have occurred through improvements in clients’ capacities for experiencing.
Gendlin (1996) originally described the concept of depth of experiencing
as a process dimension reflecting individual differences that were antithetical
to alexithymia but that were also amenable to development through effortful
practice. The 7-point experiencing scale eventually became the gold standard
for measuring good process in experiential as well as in other psychotherapies.
Shallow levels on the scale represent unengaged levels of experiencing. At
deeper levels of experiencing, which are often indicative of good process, clients
begin to puzzle over their emerging experience or use currently accessible feel-
ings to solve problems or create new meanings (Klein, Mathieu-Coughlan,
& Kiesler, 1986). This line of work helped dramatically in elaborating the
humanistic conceptualization of experiential awareness.
Pos, Greenberg, and Warwar (2009) used the experiencing scale to study
only those therapy segments during which the client discussed emotional
content, a procedure that effectively yields a precise measure of emotional
experiencing. They found that a client’s individual capacity for emotional pro-
cessing early in therapy predicted outcome, but also that the increase in degree
of emotional processing from early to mid-, or early to late, phases of treat-
ment was found to be an even better predictor of outcome than early levels of
processing or the early alliance (Pos et al., 2009). In short, a capacity for emo-
tional processing does not guarantee a good therapeutic outcome; however,
entering therapy without this capacity does not guarantee a poor therapeutic
outcome, either. Although it is likely an advantage, early emotional processing
skill appears not to be as critical as the ability to acquire and increase the depth
of emotional processing throughout therapy.
Several other studies have considered the impact of client experienc-
ing in general (and, consequently, both emotional awareness and meaning-
making) on treatment outcomes. A. Pascual-Leone and Yeryomenko (2015)
recently conducted a meta-analysis that quantified the relationship between
client experiencing and treatment outcomes using all available process out-
come studies that met certain criteria: a total of 11 studies and 458 clients.
About half of these studies examined experiential treatments, although a
number of significant data sets were also included from cognitive–behavioral,
psychodynamic, and interpersonal treatments (see Coombs et al., 2002).
Study findings demonstrated that, when peak (i.e., maximum) client experi-
encing was measured during the middle portion of therapy, it predicted symp-
tom improvements in depression, general psychopathology, interpersonal
difficulties, and self-esteem by the end of treatment. Moreover, the evidenced
effect (r = .236) was consistent across experiential–humanistic, cognitive–
behavioral, and psychodynamic–interpersonal treatment approaches. Thus,

although further studies are needed, it seems possible that client experiencing
is actually a common factor, one that is of a similar magnitude and impor-
tance as the therapeutic alliance.
Client experiencing can also be thought of in several different ways within
a causal framework. A path analysis by Pos et al. (2009) has demonstrated that,
during the middle phase of therapy, the relationship between therapeutic alli-
ance and treatment outcome was partially mediated by client experiencing.
Considering the role of another affective process, Watson, McMullen, Prosser,
and Bedard (2011) showed that the degree to which a client was able to regu-
late affect fully mediated the relationship between client experiencing and final
treatment outcomes, thereby highlighting the interrelated complexity of emo-
tional processing subtypes (e.g., experiential awareness vs. regulation).
When clients approach the meaning-laden emotions of assertive anger,
grief, or nonblaming expressions of hurt, these feelings should be deeply explored
and experienced. This process is exemplified by an excerpt from a session with
a client who had become estranged from his family and had most recently had
a falling out with his sister.
Client: Well, I’m really angry. I’m angry enough that I don’t want to
see her. And I would, ah, be very happy not to see her ever
again. [He frowns.]
Therapist: What happens inside you when you say that?
Client: [Sighs] Oh, I don’t know, just a feeling of sadness. [He shakes
his head, sighs deeply.]
Therapist: Sadness.
Client: Yeah, because we have been, since 2006 . . .
Therapist: Speak from there . . . something about the sadness.
Client: Well, it just is, uh. . . . [long pause] It means we won’t ever get
together again, to have a swim, to have a BBQ to . . . talk. . . .
Therapist: So it’s like, “I’m sad about losing her.”
Client: [Tears well up in his eyes.] Yes. I’m very sad about losing her.
[Nodding slowly; he is deeply moved. He closes his eyes.] I,
I, ahh . . . Oh! [He sighs deeply, opens his eyes, looks at the
therapist.] She more than anybody.
A new emotional awareness such as this derives from the exploration of
a single situation rather than across situations and is formulated at a relatively
low level of abstraction. Even so, clients often experience the newness felt
in such an emerging experience as a tangible moment of insight. In another
example, after a client has become aware of some previously unexplored

aspect of her experience, she elaborates on what it is like to have a moment
of emotional awareness.
Client: I’m not sure how I get to that sad feeling. [She wipes tears from
her face.]
Therapist: Uh-huh . . . and right now. . . . Where do you feel that in your
body? . . . Can you describe it?
Client: It’s there. But I think that’s the first time I’ve ever felt it.
I mean, I knew it was there. Such a big empty space. . . .
[She points to the center of her chest.] The only way I’ve been
able to explain it to people is as a “lack of direction,” an
emotional void. . . .
Therapist: Longing for something more tangible, more solid. . . .
Client: Yeah, more meaningful.
Arousal, Expressiveness, and Enactment
Although the development of awareness is essential to working with

emotion, these experiences also need to be activated in session to increase
client awareness of the associated information. The observation that emo-
tion can be targeted and evoked through physical movement has been a
long-standing technique of contemporary acting. If a scene requires an
actor to weep, he might initiate this affective process by performing congru-
ent physical actions, such as taking a deep sigh or holding his head in his
hands (Moore, 1984). The essence of this notion of working with emotion
has stood up well to experimental scrutiny. As Berkowitz (2000) reported,
when research participants were encouraged to tightly clench their fist while
recounting an angering event, they reported stronger emotional experiences
of anger. In contrast, when participants used the same fist clenching while
reporting a sad event, they felt less sadness. In short, motor expression can be
used to intensify congruent emotional experiences or to dampen incongruent
emotional experiences. These findings are important for facilitating emotion
in psychotherapy as well as for observing how clients (often outside their
own awareness) may suppress emotional experience (see Greenberg, Rice, &
Elliott, 1993; Perls, 1969).
Arousal plays a critical role in ushering in and vivifying awareness.
Although arousal might be thought of as a simple extension of awareness,
the distinction becomes a critical one when discussing the deliberate arousal
of anger in session. Greenberg and Pascual-Leone (2006) discussed a number
of studies on the treatment of depression and on the recovery of traumatic
abuse survivors in which the arousal and expression of anger were related to

positive therapeutic change such as the development of agency, self-efficacy,
and self-assertion (Beutler et al., 1991; Van Velsor & Cox, 2001). In gen-
eral, however, there are mixed findings and views regarding the relation-
ship of aroused anger (among other feelings) to therapeutic outcome, with
some evidence that venting of anger is not therapeutic (Bushman, 2002) and
becomes unproductive unless related to problem solving (Tavris, 1989) in the
service of well-articulated existential needs (A. Pascual-Leone, Gilles, Singh,
& Andreescu, 2013).
The assertion that the experience of emotional arousal in general is help-
ful is congruent with how clients see their own change process. A recent study
found that, when clients being treated for complex trauma using emotion-
focused therapy were asked what they found most helpful, they reported those
events in which they experienced high emotional arousal while exploring
traumatic events (Holowaty & Paivio, 2012). Furthermore, the blanket
view that aroused emotion was good for treatment was refined by Carryer
and Greenberg (2010), who examined the relationship between the amount
of time clients spent in aroused emotion and the outcome of their treatment.
These researchers found that, when 25% of a session was observed as contain-
ing moderate to highly aroused emotional expression, this provided an opti-
mal prediction of good treatment outcome, one that was over and above the
working alliance. When sessions with high arousal contained either more
or less duration of this arousal, they offered poorer outcome predictions. As
Carryer and Greenberg explained, this shows that a moderate amount of
arousal would seem to be the most therapeutic.
In a study of 32 clients undergoing experiential therapy for depression,
observations of increased arousal in the middle phase of treatment were a posi-
tive predictor of increased self-esteem at final outcome (Missirlian, Toukmanian,
Warwar, & Greenberg, 2005). This particular outcome relationship may speak
to an individual’s expressions of aroused emotion as helping to affirm one’s sense
of self. However, what happens, or what productive clients are doing, during
moments of high arousal remains a key issue. To that end, Missirlian et al. (2005)
also showed that, during the middle phase of therapy, the combination of emo-
tional arousal and meaning-making (perceptual processing) predicted improve-
ments in depression and other symptoms better than either process variable
alone. This finding suggests that how affect is being processed and the meaning
that clients construct from their aroused emotion determine the ultimate expe-
rience and address why aroused emotional experience might be helpful.
In short, what the arousal means or signifies to the client who experi-
ences it is an issue of chief importance that cannot be separated out from the
question of whether arousal is productive. This formulation has been conclu-
sively supported by experimental research conducted by Bushman (2002).
Thus, although arousal of emotion is clearly important, several studies have

shown that purging or venting emotion alone is not a productive process.
Rather, emotional processing is achieved through aroused expressions mainly
in the context of deeply and meaningfully articulating one’s emotional expe-
rience (Greenberg, 2002).
In an example from the treatment of complex trauma (Paivio & Pascual-
Leone, 2010), a client was disclosing for the first time her experience of being
raped by her father when she was a child. These memories had always been
highly distressing, so she would quickly shut them out of her mind, which
truncated her process. So the therapist validated this and asked for more.
Client: When I go back there, all it brings up is this rushing sense of
fear and pain.
Therapist: Yes, it must have been so painful. Can you get past that? Was
there anything else going on in your little mind as a child?
Client: [With a focused voice] I remember him saying, “Daddies do
this to their little girls.”
Therapist: Stay with that. What did you think when he said that?
Client: At the time, I was so confused. I remember thinking I must
have done something wrong, that my mother would be angry
at me. But I couldn’t figure out what I had done.
Therapist: So somehow you were at fault, a bad girl?
Client: Hmm, I never really saw it like that before, but yeah, that’s
exactly how it played out.
Here, by increasing arousal and activating the trauma memories, the client
clearly accesses information that was not previously available—that is, core
maladaptive shame and associated maladaptive beliefs about her self formed
at the time. These became available for exploration and change. How shame
can be transformed is another change process that is discussed below.
Emotional Regulation and Self-Soothing
The previous example of exploring trauma memories illustrates that there

is a delicate balance between facilitating emotional arousal in the service of
awareness and managing those very intense emotions. It is clear that in evok-
ing memories there is a range for optimum arousal; both the therapist and the
client must collaborate to develop a sense of what the most productive level is.
Generally, it is most productive when clients are able to take a reflective stance
regarding their emotions, allowing the feelings to be active yet sufficiently
regulated to be useful in the exploration and creation of new meaning. In
humanistic therapies, Gendlin (1996) was instrumental in articulating that

the level of affective intensity is an important issue to address with clients (i.e.,
when the therapist says, “Put the feeling far enough away so that you can still
tolerate it”).
Emotion regulation and associated self-soothing are essential processes
in all therapies that deal with distressing events such as trauma. In current
cognitive–behavioral approaches to complex trauma (e.g., Chard, 2005;
Cloitre, Koenen, Dohen, & Han, 2002), as well as in eye movement desensiti-
zation and reprocessing (Shapiro & Maxfield, 2002), emotion regulation strat-
egies are taught in the early phase of therapy, before trauma exploration. In
current experiential–dynamic approaches (e.g., Fosha, 2000) and in human-
istic therapies, emotion regulation is part of the overall fabric of therapy and
is accomplished largely through provision of a safe and empathic therapeu-
tic relationship, which provides the foundation for exploring and processing
painful traumatic experiences.
Therapists should be mindful of clients’ capacity for emotion regula-
tion in the early phase of therapy, when painful emotions are explored for the
first time. Later, in the working phase, clients will often need to be coached
through self-soothing and regulation strategies (i.e., breathing, positive self-
talk, making use of physical comforts, and appropriate self-distractions) both
to tolerate and to work through painful emotions. Facilitating regulation is
important when clients are overwhelmed by undifferentiated feelings such
as global distress, secondary emotions such as rage, or primary maladaptive
emotions such shame or fear, as in panic attacks. The short-term goal of emo-
tion regulation is to gain psychological distance from these experiences, to
help clients turn down the intensity. Until this happens, painful emotion not
only remains unarticulated in the moment but also is not experienced in detail
(A. Pascual-Leone, 2005; Stern, 1997) and therefore cannot be a useful source
of information or guide adaptive action.
Therapist interventions in humanistic and experiential therapies that
facilitate emotion regulation vary depending on a client’s level of dysregulation.
In the short term, explicit use of skills training exercises, similar to those
used in cognitive–behavioral therapy in the treatment of fear and avoidance,
are helpful. The long-term goal of facilitating emotion regulation in these
instances is to help the client develop a repertoire of strategies for coping with
intense feelings. Such methods of emotion regulation are illustrative of how
humanistic and emotion-focused approaches may draw on and integrate inter-
ventions from nonhumanistic models. Clients may be experiencing intense
and painful emotion, but it remains bearable, at least for the time being. This
was the case with the client described above, who was remembering the rape
by her father. Distress that is intense yet bearable is a marker for empathic
affirmation of client vulnerability, followed by therapists helping clients to
articulate the meaning of their emotional pain.

Experiential therapists have long argued that symbolizing bodily felt emo-
tional experience can decrease emotional arousal (Paivio & Laurent, 2001).
For example, a study that encouraged girls to use emotion diaries found that
the simple practice of disclosing and tracking emotion reduced anxiety symp-
toms, particularly for girls who had difficulty coping with emotion (Thomassin,
Morelen, & Suveg, 2012). Recent research from affective neuroscience has
corroborated these clinical and experimental observations. Findings from a
study using functional MRI demonstrated that, when healthy participants
were presented with distressing images and then given the opportunity to label
their feelings with words, it reduced the activity in their amygdala (Lieberman
et al., 2007).
Furthermore, this process of using symbolization as soothing operates
individually as well as interpersonally. The process of soothing through mean-
ing happens interpersonally when a therapist who is empathically attuned
tentatively captures a client’s affect in just the right words, expressing it in a
way that also conveys acceptance and validation. Internal security develops by
feeling that one exists in the mind and heart of the other; thus, the security of
being able to soothe the self develops by internalizing the soothing functions
of a protective other—perhaps the therapist (Fosha, 2009; Schore, 2003). The
long-term goal of such empathic and dyadic regulations of affect is to help
clients develop their capacity to calm and comfort themselves by internal-
izing the soothing responses of the therapist, as well as by constructing mean-
ing that makes distressing experiences more comprehensible and manageable
(Greenberg & Pascual-Leone, 2006; Paivio & Laurent, 2001).
As an example, a client who suffers from social anxiety and depression
and is in the middle phase of treatment describes his feelings of shame in
social settings. Although the client becomes highly distressed, his therapist
joins him in empathically exploring the meaning entailed in this very painful
emotion.
Client: Umm. Everything I say is just a bit off, you know . . . off
of how other people see or . . . talk about things. [His voice
cracks, and he breaks down, sobbing heavily.]
Therapist: It’s just really. . . . It hurts to say that. . . . Can you say what
hurts so much?
Client: [He sniffles. There is a long pause; he seems lost for a moment in
his pain.]
Therapist: It’s just a feeling of inadequacy that gets pulled . . . or . . .?
Client: Well, yeah, I have to monitor everything I say, even while
I’m saying it, because I’m . . . I know, or feel, that everything
I say is just a little bit off, just doesn’t. . . . You know, people
will just do a double take or disregard me as a nutcase.

In this example, instead of deflecting his emotion or breaking down
into despair, the client begins to follow the therapist’s attentive and empathic
initiative and starts to articulate the meaning of his feelings. In so doing, the
dyadic process serves to regulate his arousal from sobbing back into a manage-
able range in which meanings can be explored.
Reflection on Emotion and Active Meaning-Making
The process of reflecting on emotion results in increased self-awareness;

however, clients also use narratives to explain their experiences and to under-
stand why emotion is aroused (and comes into awareness). Research has shown
across a number of contexts that being able to contextualize and explain
painful emotional memories promotes their assimilation into a coherent per-
sonal narrative, which in turn promotes healing (Angus & McLeod, 2004;
Pennebaker & Seagal, 1999). Thus, narrative accounts, or the stories one tells
about emotion experiences, play several roles in contextualizing, integrating,
and assimilating these experiences. Reflection on emotional experiences then
provides an evolving interpretive verbal and cultural framework, which entails
self-narratives and personalized themes that begin to interact with, and color,
the nature of emerging experience (Angus & Greenberg, 2011).
Furthermore, creating narratives about oneself also requires internal coher-
ence (J. Pascual-Leone, 1990; Pennebaker, 1997). In the context of traumatic or
depressogenic events, individuals sometimes make appraisals about themselves,
others, or the nature of events that are later shown to be untenable. Paivio
and Pascual-Leone (2010) gave the example of a woman who recalled how her
parents “helped” her with homework during grade school. She described her
emotionally volatile mother leaning over, screaming at her as she struggled with
homework late at night. She also recalled periodic beatings by her father that
followed any wrong answer during these late homework sessions. As an adult in
treatment, she remembered weeping as a child, feeling exhausted, and thinking
how she was obviously unintelligent and inadequate. However, after reflecting
on the terror she felt, she eventually concluded that any child, or even any adult,
would have had difficulty performing under those conditions and that perhaps
she was not given a fair chance. From a cognitive perspective, reflecting on emo-
tion can be understood as a way of changing a client’s assumptive framework
(i.e., schema; see Beck, Freeman, & Davis, 2004).
From an existential point of view, reflecting on emotion can result in the
insight that one is not only the reader but also the author of one’s life story.
The prototypical existential insights described by Yalom (1981) are essential
reflections that recontextualize distressing emotion, offering a new interpretive
framework, as in (a) “Only I can change the world I have created,” (b) “There is
no danger in change,” (c) “To get what I want I must change,” and (d) “I have

the power to change” (pp. 340–432). Reflexive states such as these are simple,
yet profound. Although they can always be entertained from an experience-
distant position as theoretical possibilities, their full and real impact is only
appreciated when they are lived moments of awareness rather than items of
conceptual or behavioral learning. To that end, Gestalt therapy has highlighted
intentionality rather than insight per se (Perls, 1969). Thus, the experiential
emphasis is on experience and process (what the client feels and how it is expe-
rienced or done) over content and cause (what is being talked about and why
the client experiences or does things).
Given the fundamental humanistic position that the client is the agent
in the development of his or her new insight, one common intervention for
facilitating reflection on emotion is to explore collaboratively any troubling
reactions clients may have to situations they have encountered. When clients
express confusion or describe having felt puzzled by their own emotional reac-
tions in a given situation, it is a marker to facilitate reflection on that experi-
ence (Angus & Greenberg, 2011; Rice & Saperia, 1984). Overall, reflection
on emotion and its circumstances can help clients with “re-storying” the pain-
ful experiences they have lived.
In psychotherapy, insight often involves reflection on emotion. A tra-
ditional psychodynamic interpretation, for example, is usually based on the
therapist’s appraisal of core themes relevant to the client (e.g., “This seems a lot
like the kind of powerlessness and depression you used to experience with your
father. Rather than experiencing your rage, you collapse”). Some experiential
therapists may choose to guide the client process, but they do not presume to be
experts on the client’s experience or dynamics. Following this position, thera-
pists encourage their clients to articulate insights about emotional experience
as those insights emerge from the client’s perspective. Finally, reflection on
emotion is also facilitated by modeling a discovery-oriented approach in which
therapist and client alike are trying to understand the client’s story of emotion
(Therapist: “Somehow you collapse into feeling like that powerless little boy.
How does that happen? What goes on for you on the inside?”).
The following excerpt is from a session with a client suffering from
depression. She has begun by discussing her marital difficulties, which leads
to her speaking about her relationship with her children. She notes a theme
and goes on to elaborate reflection on her emotional style:
Therapist: Oh, so you can’t accept love just for being who you are?
Client: [Talking rapidly] No. I owe them. Somebody . . . I owe my
children when they do something nice for me. I owe them so
big I could never buy them enough gifts. I am so touched that
somebody bothers to love me. It’s so big for me. I think . . . I’m
starting to formulate something here in my mind. [Her speech
slows and becomes focused.] Give me a second. . . . I think I

turn people off, so I don’t have to owe. I’m just realizing that
at this moment in time . . . because I turn a lot of people off.
And it seems to me—Why would I do that? I mean, that’s
like shooting yourself in the foot. . . . But I think I do that
simply for the purpose of not having to owe them. I just
discovered that.
Notice that this example of an in vivo reflection on emotion involves a
more top-down process, in which the client makes connections and identifies
a pattern that applies across situations. Taking a bird’s eye view has powerful
advantages at certain moments; clients may develop a more contextualized self-
understanding and self-interpretative framework. A link that is self-discovered,
as above, or, better yet, “self-created,” will always fit one’s own experience best.
Moreover, emotional knowledge that is attained through one’s own efforts is
more likely to be retained than if it has simply been conveyed (A. Pascual-
Leone & Greenberg, 2006).
Emotional Transformation or Changing Emotion With Emotion
After relationship conditions have been established, and after the initial
contact in emotional awareness, deepening of experience, and clear expression,
experiential therapies move toward transforming emotion. Such approaches
use a process-guiding style to create change by evoking affect to promote emo-
tional processing and access to additional material (Greenberg, 2002). Rice
(1974), a pivotal influence on Greenberg and the development of emotion-
focused therapy, was one of the first to underscore the evocative function of
a client-centered therapist. Thus, after previously unacknowledged experi-
ence has been accessed, the focus shifts to transforming certain emotional
experiences by using emergent and alternative emotions to expand a person’s
repertoire.
The term emotion scheme is often used to capture the dynamic nature
of emotion as a multimodal network of feelings and meanings (i.e., a self-
organization) that could exist in one’s repertoire at various levels of activa-
tion (Greenberg et al., 1993). Attending to a current (maladaptive) emotion
scheme that is in need of transformation, such as feeling worthless, makes it
accessible to new inputs that might change it. Identification of and attention
to unfulfilled needs embedded in a maladaptive state stimulate alternative
self-organizations, which are tacit, emotionally based schemes; they begin to
organize the individual toward meeting an identified need. It is the synthesis of
this new possibility with the old ones that leads to lasting change (Greenberg,
2002; Greenberg & Watson, 2005; A. Pascual-Leone & Greenberg, 2007).
Thus, experiential approaches of this kind make use of the power of affect to
catalyze change, producing a restructuring of core emotion-based schemes.

This access to alternative responses, along with the synthesis of old with new
schemes, is viewed as central to therapeutic change. On a neuronal level,
withdrawal emotions from the right hemisphere of the brain can be trans-
formed by the activation of approach emotions from the left prefrontal cortex
or vice versa (Davidson, 2000). Changing one emotion by way of another
occurs as a client gains new meaning from a freshly emerging emotion, result-
ing in newly formed neural connections and increased efficiency of neural
information transfer (Davidson & Begley, 2012).
Emotional transformation is not simply the process of generating new
experiences in therapy, because it does this by using facets of another, already
present maladaptive emotion. This is possible because there can be coactiva-
tion of adaptive emotion along with, and in response to, maladaptive emotion
(Greenberg, 2002). Although it is implicit in most humanistic therapies, one of
the explicit principles in emotion-focused therapy is to respond empathically to
distressing, even maladaptive, emotion while continually supporting the tenta-
tive emergence of adaptive emotional responses. In this way, bad feeling is not
purged or vented as such, nor does it attenuate; rather, another feeling is evoked
in parallel and in contrast to the maladaptive feeling (Fosha, 2009; Greenberg,
2002; A. Pascual-Leone & Greenberg, 2007).
As Fredrickson (2001) has observed, key components of positive emo-
tions are simply incompatible with negative emotions. Although adaptive
emotions (e.g., grief, assertion) are not necessarily positive (i.e., enjoyable),
the transformation of emotion as described above hinges on a similar prin-
ciple: Activating a new emotion actually changes the preceding emotion. In
a series of laboratory experiments demonstrating this, Fredrickson, Mancuso,
Branigan, and Tugade (2000) showed that cardiovascular effects of a nega-
tive emotion (i.e., anxiety) were not simply replaced but rather undone by
positive emotions (i.e., contentment and amusement). In short, compared with
neutral control procedures, positive emotions accelerated cardiovascular recov-
ery. Similarly, in a psychotherapy analogue study of self-criticism (Whelton
& Greenberg, 2005), people who were more vulnerable to depression showed
more self-contempt but were also less resilient in response to their own self-
criticism than people who were less vulnerable to depression. Meanwhile,
less vulnerable individuals were able to recruit assertive emotional resources
such as pride and anger to combat (transform) depressogenic self-contempt
and negative cognitions. Together, these studies indicated that emotion can
be used as a means to change emotion.
However, this dualistic conceptualization (positive–negative, approach–
withdrawal) of sequential patterns of change has been further developed by
an empirically derived model proposed by A. Pascual-Leone and Greenberg
(2007; A. Pascual-Leone, 2009). By coding emotion states from the videos of
34 sessions of experiential therapy for depression and interpersonal injuries,

these researchers identified a multistep sequential pattern of emotional
change that predicted outcomes. Using moment-by-moment analyses, they
showed that distressed clients first worked through emotions that are global,
undifferentiated, and insufficiently processed. Fear, shame, or rage then rep-
resented a second step, characterized by a deep, enduring, yet familiar painful
state, which was highly idiosyncratic and often anchored in generic autobio-
graphical narratives. Further on, at the third step of processing, articulation of
a core negative self-evaluation was contrasted with an existential need, serv-
ing as a pivotal step in change and occasionally producing a sense of relief.
A fourth step described a set of adaptive emotions. On one hand, clients
entered a state of grief, in which they acknowledged personal losses without
complaint or self-pity. On the other hand, clients mobilized through asser-
tive anger or self-compassion, in which they proactively affirmed a healthy
entitlement to experiences of personal competence, worth, and connection
with others. Eventually, a synthesis of these adaptive emotions (i.e., assertive
anger, grief, self-compassion) led to the resolution of distress and facilitated
resolution of personal difficulties.
The most common targets of emotional transformation and interven-
tion are primary maladaptive fear, shame, or loneliness, which are complex
and dysfunctional affective meaning states that tacitly embody a sense of
being incompetent or bad and unlovable. They are embodied preverbal expe-
riences (schemes) that are not easily amenable to logical or rational change.
In the example of the client described above who had been raped, she stated,
“I know that he was the adult and I was just a child, but I still feel like I was
responsible.” Another client said, “I know in my mind that I’m successful—
I have a PhD, for God’s sake! But I still always have this sense that there’s
been some misunderstanding or clerical error.” The fact that these feelings
defy rational thinking makes it difficult to change maladaptive emotion
through reason and seems to highlight the need for experiential over cogni-
tive approaches to emotional change.
In sum, primary maladaptive emotion is transformed by accessing and
evoking primary adaptive emotion. This process often occurs later in the work-
ing phase of treatment. Although the transformation process cannot be
applied formulaically because it is contingent on each individual’s personal
experience and idiosyncratic meaning, A. Pascual-Leone and Greenberg’s
(2007) process research has supported the idea that a series of prototypic
pathways exists. Maladaptive fear, for example, about being preyed on by
potentially abusive others, can be transformed by supporting the simulta-
neous emergence of assertive anger, in which clients actively defend their
boundaries and dignity (Paivio & Pascual-Leone, 2010). Similarly, shame
and maladaptive self-blame can be transformed by accessing feelings of anger
about injustice (Whelton & Greenberg, 2005). Working through anger,

moreover, can be facilitated by subsequently moving to deeper experiences
of sadness (Rochman & Diamond, 2008).
Some therapist interventions that facilitate emotional transformations
in experiential therapies have been studied in detail. First, Gendlin’s (1996)
focusing exercise often results not only in awareness of a particular emotion,
but also in emotional transformation. Second, enactment tasks and imagi-
nary dialogues are effective ways of activating contrasting emotions while, at
the same time, keeping emotions symbolically and experientially delineated.
Thus, in the context of unresolved feelings toward others, imaginal confronta-
tion (as used in emotion-focused and Gestalt as well as some other therapies)
is a principal way of facilitating emotional transformations (Greenberg &
Malcolm, 2002; Paivio et al., 2001). In the context of self-related difficulties,
two-chair enactments between different and incompatible parts of the self are
useful (Greenberg et al., 1993; Whelton & Greenberg, 2005).
Of course, these enactments are ultimately built on the experiential
bedrock of evocative elaboration (Rice, 1974). To move through an emotion,
clients are encouraged to “stay with the feeling.” Therapists who are empathi-
cally attuned gently guide the clients’ attention to facets of their experience
that may only be in the periphery of awareness (Gendlin, 1996). This role of
the therapist’s empathic attunement is highlighted in both humanistic and
experiential–dynamic perspectives, in that a key target of emotional trans-
formation is a client’s feelings of aloneness in dealing with overwhelming
emotions (Fosha, 2009).
In the following excerpt from therapy, a woman diagnosed with dysthy-
mia and a major depressive episode describes her relationship with her father,
who became emotionally withdrawn after her mother died. The client begins
in a state of maladaptive shame, feeling as though there were something about
her that deserved to be rejected. As she explores this feeling, there is a sense
of anger; the therapist then guides the client’s attention toward those aspects
of the unfolding experience, thereby transforming her sense of worthlessness
into self-assertion.
Client: He was never there for me. All the suffering I put myself
through—I guess I have only myself to blame.
Therapist: So, there’s this sense of somehow not deserving love. . . .
Client: [Tears fill her eyes.] I feel I’ve had too many losses in my life.
It seems so unfair. I had to deal with so much on my own. I
hate him for what he did.
Therapist: Tell him what he did. [Points to empty chair.]
Client: I don’t think you realize . . . all my relationships, everything,
has been so much harder . . . because of the way you treated
me. Every single day I’ve had to fight through that. . . .

Therapist: What do you resent? Tell him.
Client: I resent that you didn’t love me. I hate you for being so self-
ish, inconsiderate, and dismissive of me and [pause] . . . for
just never putting me first. [shrugs] Not that I needed that
always. . . .
Therapist: What just happened there. . . . Something changed?
Client: I’m feeling sorry for myself.
Therapist: OK. Try not to go there, stay with your resentment for
now. . . . I know it’s difficult, but tell him more about your
resentment.
Client: [She turns back to squarely face the chair.] It’s hard for me to
confront you, but this I must say: You were not a decent
father to me. You abandoned and neglected me . . . for most
of my childhood . . . and I’m angry at you for that.
In this example, maladaptive shame undergoes a microtransformation as sub-
dominant feelings of anger and healthy entitlement are brought to the fore-
ground. Through this process, the client eventually expresses adaptive assertive
anger, which is supported by the therapist over the course of therapy until it
becomes a new, healthy, and more stable part of the client’s repertoire.
FROM RESEARCH TO PRACTICE: THERAPEUTIC

APPLICATIONS OF HUMANISTIC–EXPERIENTIAL
PRINCIPLES FOR WORKING WITH EMOTION
The emphasis on moment-by-moment client process is a fundamental

tenet of all humanistic and experiential therapies. This unique attentiveness
to emerging experience is a special advantage of this therapeutic approach
when working with emotion. As a result, the tradition has developed a num-
ber of implicit and explicit principles of intervention. In this section, we
discuss emotion in practice and how therapists work with emotion.
The Relationship as the Crucible of Emotion Change
Although today most approaches to therapy acknowledge the importance

of working with emotion, the fact remains that some qualities of the therapeu-
tic environment are more conducive than others to the exploration of affective
experience and meaning. Cultivating these qualities can be particularly impor-
tant when working with clients who have learned to minimize or fear their
feelings. In this section, we offer guidelines for cultivating an environment

that facilitates deeper emotional experiencing, a process that begins in the first
session of therapy and continues thereafter.
Maintain a Consistent Focus on Feelings

Promoting experiencing is an essential part of emotion coaching that
begins in the first session of therapy and (implicitly or explicitly) will be an
important task that contributes to alliance development. As such, therapist
responses that frame problems in feeling terms and communicate that valu-
ing of emotional experience and expression are the foundation for deepening
client experiencing (e.g., “This must be so painful—it’s like you are your own
worst enemy” or “So lonely to keep that secret all these years”). Responses that
focus on affective experience implicitly and sometimes explicitly give the client
permission to experience and express what are often confusing, frightening,
and intensely negative or painful feelings. Therapy, like any social engagement,
is filled with subtle cues that indicate to clients what type of behavior and what
tone is acceptable, desirable, or appropriate. Valuing and validating emerging
feelings communicates to clients that the usual restrictive social norms con-
cerning intense emotion do not apply in this context (e.g., Therapist: “I under-
stand part of you must really hate him for what he did”; Client: “I do. I hate him.
I used to wish he was dead, and then I’d feel guilty”) and that emotions are not
inherently dangerous. This is especially important with clients who fear others
will minimize, misunderstand, or judge their feelings.
This focus on feelings is not only central to exploring affective mean-
ing but is considered essential to the task of processing painful memories in
general. Research from a variety of theoretical perspectives has indicated
that a cognitive emphasis is counterproductive to the emotional processing
of trauma memories. A recent meta-analytic review (Foa, Rothbaum, & Furr,
2003), for example, concluded that, when exposure therapy is augmented
with other cognitive interventions, the combination can actually decrease
the effectiveness of treatment with respect to emotional processing. This
finding suggests that a cognitive emphasis can impede working through dif-
ficult emotions, perhaps because it serves as a distraction from affect.
Another line of research has argued that the rumination characteristic
of worry is distinct from and antithetical to the working through that is nec-
essary for emotional processing (Borkovec, Alcaine, & Behar, 2004). Worry
is understood by these researchers as a cognitive response that allows one to
avoid deeper pain and more primary emotional experience. The cognitive,
verbal–linguistic behavior of worry suppresses potentially evocative imag-
ery, underlying meanings, and even somatic activity. In this way, rumination
can block the natural course of experiential processing. Thus, effective inter-
ventions direct clients’ attention to exploring core emotions that underlie
chronic worry (e.g., a core sense of self as inadequate, fragile, or flawed).

Ensure Optimal Arousal
Very high levels of arousal interfere with the capacity to explore meaning.
Clients who are processing a profound loss, for example, may need to have a
good cry, but arousal must diminish before they can really explore the meaning
of the loss in their lives. Even so, arousal must be sufficiently high to activate
relevant emotional meanings. Thus, to promote experiencing, interventions
need to help clients modulate levels of arousal.
Cultivate a Client’s Attitude of Curiosity and Exploration

Interventions that encourage clients to pay careful attention to their
feelings, needs, concerns, and perspectives promote an attitude of interest in,
respect for, and valuing of their emotional life. This can be made explicit as
part of collaborating on the task of exploring affective meaning (e.g., “I hear
how much this distresses you, and I guess it seems important to get a sense of
how this unfolds for you, how you always end up feeling like the bad guy” or
“So, somehow it’s hard to believe you deserve better?”). In addition, clients
need to be aware that experiencing may result in both discovering and creat-
ing meaning and that answers to their problems do not exist a priori. This
helps to promote tolerance for ambiguity as well as client agency in solving
emotional problems.
Create an Environment Conducive to an Internal Focus

Initially, many clients are often focused on describing external situations
and the behavior of negative or abusive others, or they may talk continuously,
making it difficult for the therapist to intervene at all. Interventions in these
instances need to help the client relax and slow down the process (e.g., “Wait,
wait, so all this was going on and I’m wondering—what’s it like for you to tell
this story? This is worth slowing down for. Take a minute. . . . What’s going on
inside as you tell me this?”). The aim is to help clients become introspective
and self-reflective and learn to be comfortable with a pensive silence so they
can “hear” their internal processes. This applies to recognizing and attending
to positive as well as negative experiences. As Fosha (2000) and others have
argued, successful therapy also includes recognizing, attending to, and explor-
ing clients’ positive emotions.
Maintain Interpersonal Contact

Experiential processing takes time, and clients vary in the amount of time
they need to symbolize and fully process a given experience. Productive silence
can occur naturally when the client is searching internal experience (Levitt,
2001). Therapists would do best to attend patiently to these moments and resist

filling in the spaces. However, silence should not go on for too long, because
clients can easily lose focus or direction. The principle here is to respect the
client’s need for silence and at the same time maintain contact. Therapists
periodically need to invite clients to share what they are experiencing (e.g.,
“Can you tell me what you are thinking or feeling right now?”). Constructing
meaning is a collaborative rather than a solitary process, and it cannot be
prescribed. When processing is productive, clients will typically share their
experience (e.g., “I was just thinking how strange it is that I have let this go
on for all these years; sad, really”). Therapists will then respond with empathic
reflections that work roughly within the client’s horizon of experience (e.g.,
“Hmm, so there is this sense of feeling both grief and feeling puzzled, as we
begin to unpack this together”).
Intervention Principles for Promoting Emotional Experience
A client’s level of engagement often involves reexperiencing the narrated

past (e.g., “I remember sitting alone, thinking there must be something wrong
with me”). At the same time, the client must remain engaged with the pres-
ent moment, which sometimes contrasts and at other times complements or
informs the past narrative (e.g., “Now that I tell the story, I feel angry about the
betrayal I suffered”). Productive experiencing is characterized by an internally
focused vocal quality that indicates a reflection that is unrehearsed and search-
ing (Rice & Kerr, 1986). Often there are pauses as the client concentrates and
gropes toward new meaning. These pauses are indicative of good process and
should be encouraged and supported by the therapist (e.g., “Stay with that,
take your time” or “Keep your attention on that gut feeling, it’s important”). Of
course, externally oriented clients eventually return to their default of describ-
ing situational events and related cognitions, but these repeated forays into
idiosyncratic meanings and feelings facilitate experiencing (Angus & McLeod,
2004; Paivio et al., 2001).
Differentiate Hurt, Upset, and Global Distress

Emotional experience needs to be sufficiently specific before the under-
lying facets of experience can be put into words. As discussed earlier in this
chapter, when a client’s experience is undifferentiated, hurt, upset, or dis-
tressed, then the client cannot hope to articulate any specific meaning, which
emerges only from an increasingly specific emotional experience. Thus, dif-
ferentiating global upset or distress into discrete emotions is a necessary step in
promoting exploration of meaning and thereby moving the emotional process
forward (A. Pascual-Leone & Greenberg, 2007). Again, this is because discrete
emotions are associated with specific information used in the construction of

new meaning. Promoting experiencing thus requires exploring and integrat-
ing the context-relevant meaning associated with specific discrete emotions.
Explore All Facets of an Emotional Episode

Any important affective event is encoded as a multimodal network of
information (i.e., an emotion scheme or structure), and experiencing entails
activating the structure to explore its components deliberately. When a
client definitively states that he or she feels a certain way (e.g., “Well, it’s just
embarrassing, nothing else”), many therapists who are learning to work with
emotion have difficulty knowing how to explore the issue further; if this hap-
pens, the therapy process can become stuck or redundant. However, labeling
an emotion is only one part of the process; because most of the elements in an
emotional experience are tacit, unpacking or elaborating that information, or
meaning, facilitates client experiencing.
In an effort to describe the components of an emotional experience
in response to a given situation, researchers (Greenberg & Korman, 1993;
Pos, Greenberg, Goldman, & Korman, 2003) have focused on segments in
therapy in which clients disclosed past or present emotional experiences.
Although this was initially intended as a research strategy, being familiar with
the essential components of these kinds of moments can provide direction
for therapists intending to explore a client’s feelings beyond simply labeling
them. Accordingly, when a client refers to a particular feeling (e.g., sad, happy,
afraid, embarrassed), the given emotion usually entails the five following ele-
ments, or facets, of experience, each of which might be a point for exploration.
1. Situation or interpersonal context. This is typically the stimulus or
circumstances of the emotion (e.g., “I have failed in my marriage”
or “My mother left me alone”).
2. Action tendency. Because one of the purposes of emotion, evolu-
tionarily speaking, is to organize a person to express some response
or behavior, emotional experiences are almost always accompa-
nied by some kind of action, or an impetus toward action. In
fact, sometimes clients first present an action tendency (e.g.,
“I wanted to crawl into bed and pull the covers over my head”).
3. Somatic component. Emotions are embodied (Damasio, 1999).
Working with the somatic component of emotion is particularly
elaborated in focusing, Gestalt, and experiential body-based
therapies. Unlike action tendencies, these somatic elements
are not usually indicative of particular goal-oriented behavior;
rather, as described by Gendlin (1996), they represent a pre-
verbal aspect of meaning that can be captured in metaphors or
images (e.g., “I have butterflies in my stomach” or “I feel warm

inside, imagining her beside me”). Focusing (Gendlin, 1996) is
a technique that can be especially useful for elaborating affec-
tive meanings via the somatic component of an experience.
4. Unmet existential or interpersonal need. When emotions are dif-
ferentiated enough, they organize people for action toward some
implicit goal. Thus, therapists need to be attuned to core exis-
tential and often interpersonal needs that drive affective and
cognitive goal-oriented behavior. The verbal symbolization of
existential or interpersonal needs is pivotal in the full elabora-
tion of the meaning of these experiences (e.g., “I needed love,
affection, even just some acknowledgment that I was there!” or
“What he did was just wrong—we deserve justice!”).
5. Concern regarding the self or self-in-relation-to-other. The articulation
of self-related difficulties (e.g., feelings of insecurity, worthlessness,
or harsh self-criticism) usually emerges as the client explores the
effects that difficult experiences have had on personal identity,
hopefulness, and relatedness to others (e.g., “Maybe I’m just an
angry person; I wish I weren’t like that”). Concerns about the
self are usually relatively easy to access in clients who are already
emotionally aroused; sometimes it is sufficient to guide a client
from the situation and circumstances to focusing more on the
personal ramifications it may have (e.g., Client: “She just stood
there and watched him beat the crap out of me!” Therapist: “So,
somehow that says something about both of you—the fact that
she didn’t intervene?”).
Awareness of these five aspects of an emotion episode can be a useful strat-
egy for deciding where and how to explore further when therapists feel stuck
and clients present their feelings as deceptively straightforward. Moreover,
because these elements of an emotion structure are linked together in a net-
work, elaborating one such facet of experience can lead to all the others.
Addressing each of these facets is a potential avenue for further exploration.
Move From Concrete to More Abstract Aspects of Emotional Experience

The principle of exploring all facets of an emotion scheme assumes that
experience needs to be activated. To make an emotion vivid in a client’s
immediate experience, one could begin activating the network with any of
the components described above. However, when clients are not aware of spe-
cific emotions, exploration moves best from concrete sensations (i.e., bodily
felt sense, action tendencies, concrete images) to more complex and abstract
aspects of experience (i.e., thoughts, feelings, desires, and needs), not vice
versa (Paivio & Pascual-Leone, 2010).

In treatments such as emotion-focused therapy, focusing-oriented therapy,
eye movement desensitization, reprocessing therapy, or even anger manage-
ment therapies, for example, clients are explicitly taught to use bodily expe-
rience as a source of information about emotion or arousal states. However,
the higher aim of this experiencing is to symbolize the meaning of affec-
tive experience, not just to be attuned with one’s bodily experience. For
example, “I’m flushed and angry” is useful, embodied, and concrete infor-
mation, but the more abstract meaning of “I’m fighting for my dignity” will
capture what is most important. Although both are needed, the latter is
a higher level process or skill than just creating an awareness of affective
experience.
In contrast, if clients can already identify their feelings (e.g., anger),
directing attention to their associated bodily experience will not typically move
the meaning-making process forward. Similarly, if clients already know what
they want or long for (e.g., abstract experience—the need to be treated with
respect) and that need is vividly experienced in the moment, then directing
a client’s attention toward bodily sensations (e.g., concrete experience—
feeling hot and the impulse to lash out) will not usually move the process
forward (e.g., see A. Pascual-Leone et al., 2013). In these situations, when
clients are already aroused and in touch with the more complex and abstract
aspects of their experience, it is more useful to move directly to helping them
articulate the meanings associated with those feelings in the context of self,
others, and interpersonal relatedness (e.g., “I guess, this is you fighting for . . .
respect? For what’s decent?”).
Listen for the Implied Message

Most training manuals on basic psychotherapy and counseling skills dis-
tinguish between the explicit and implicit aspects of a client’s communica-
tion, emphasizing the importance of responding to the implicit message. In
experiential therapies, this has been called responding to the leading edge
of experience (Gendlin, 1996) because responses that highlight this aspect
of experience move the process beyond what is merely being stated. Thus,
empathic reflections, directives, questions, or interpretations that focus on the
implied message promote deeper experiencing (e.g., Client: “She’s the adult,
she should be looking after that, not me!” Therapist: I hear how much you
resent being saddled with that burden, almost being her mother rather than
the other way around. I imagine you would love some mothering of your own
at times”). The caveat is that the therapist is responding to a client’s intended
message, which is on the periphery of awareness, not to material that the
client wants to keep hidden or private. Responding to the intended message
stands in stark contrast to making deep and often dynamic interpretations that

are not in the periphery of awareness, or confronting a client’s defenses, which
can evoke feelings of shame and defensiveness.
Therapists can respond to a client’s implied message by making small
inferences or attending to overt nonverbal cues. As clients explore, the focus
of their attention shifts from what was an implicit meaning in one moment
to an explicit expression of that meaning, dynamically moving the dialogue
forward. Even so, some affective meaning is beyond the reach of the client’s
verbal symbolization. The client experiences this implicit meaning as a pre-
verbal intuition—a felt sense, to use the words of Gendlin (1996). Therapist
responses that capture this aspect of experience might glean meaning from,
say, the client’s tone of voice, an unanticipated pause or pattern of speech, or
incongruence between the implicit and explicit message. When a therapist
is able tentatively to put words to this felt sense, clients often immediately
recognize it as their own intended meaning. This process of tentatively offer-
ing the client meaning that may be barely be out of reach provides a scaf-
folding that expands the client’s horizon of awareness, thereby facilitating
experiencing.
Attend to Less Dominant Affective Meanings

Emotional experiencing is a highly dynamic process. Whether an exist-
ing affective state is an ephemeral one or a stable feature of the client’s per-
sonality, the most salient experience is always in dynamic competition with
other lesser activated states, as with emotions that are just outside the client’s
focus (A. Pascual-Leone, 2009). These potential states can be thought of as
subdominant experiences that exist in the background, yet bleed through
and color the dominant affective meaning state, sometimes in subtle ways
(Greenberg & Pascual-Leone, 1995). This is comparable to Gestalt (Perls,
Hefferline, & Goodman, 1951) ideas of conflict between the dominant top-
dog side of personality and the weaker experiencing self, or underdog, and to
current constructivist views of multiple selves or voices working in harmony
or disharmony (Hermans, 1996; Stiles, 2006). Subdominant experiences
often characterize those more fragile parts of the self that embody authentic
feelings and needs, along with adaptive resources that have been squashed
or damaged by trauma or other painful experiences. Therapists looking to
facilitate an emotional transformation in their clients by way of experiential
exploration need to be attuned and responsive to these less activated and
more subtle emotional organizations.
Consider a client whose core sense of self is that she is worthless, or bad.
This maladaptive state or emotion scheme is a network of feelings and mean-
ings that gets activated across situations. Perhaps the sense of being bad is
elicited in therapy by imagining a critical ex-spouse. The client describes the

most salient facet of her experience as fear of being berated by the spouse. As
she describes this experience, she sometimes lowers her eyes in what might be
embarrassment or shame and sometimes grits her teeth in what seems like a
flicker of anger. She describes wanting to freeze or hide, and, as she says this,
she firmly grasps the armrest of her chair. Unmet needs for security, safety,
and protection are at the center of the maladaptive experience of fear. As
these thoughts and feelings are activated in therapy, they leave her drained of
energy and with a sinking feeling in her stomach. Part of the implicit mean-
ing entailed in this state is captured by her thoughts of “I’m bad” (shame),
“There’s nothing I can do about it” (powerlessness), or even “I’m going to get
it!” (fear), but she also says, “I hate him” when referring to her ex-husband.
Therapists attuned to the nuances of experiential process implicitly
notice signs of shifting affect and meaning in the form of nonverbal cues, frag-
ments of meaning, or emerging incongruous emotion. In the above example,
fear is the dominant aspect of experience, and shame and anger are subdom-
inant. Therapist interventions could focus on either of these subdominant
aspects, depending on the intentions of intervention. In the earlier part of
therapy, the therapist might want to focus on exploring the underlying shame
that prevents the client from holding the spouse accountable for harm. As ther-
apy progresses, however, the therapist may want to increase the client’s aware-
ness of her adaptive anger at maltreatment and possibly help her express this
to the imagined husband, which may or may not be practice for a real-life
confrontation. In such a case, the therapist would be attuned to ephemeral
moments when the client grits her teeth, clenches her fists, deepens her voice,
and expresses anger toward her abuser. By drawing attention to these traces
of anger, interventions orient the client’s attention to a different set of affects
and meanings besides fear, such that they gradually move to the foreground.
Any verbal or nonverbal sign of the subdominant emotion scheme could be
used as a point of elaboration. For example,
Client: [Under her breath, clenching her teeth] I hate him.
Therapist: Yeah, hate him, like he’s a big bully, picking on you and
scaring you. I’m sure you’d like to make him go away, leave
you alone!
or
Therapist: I notice your clenched fists, like you just want to fight
back. . . . Does that fit?
Finally, facets of experiences that are attended to always become
increasingly salient; as the newly emerging process is symbolized in words,
the once subdominant experiences of assertion and anger shift to the fore-
ground and become dominant, and the experience of maladaptive fear

becomes background, at least for the time being. When anger is attended to
and accessed, the client feels she wants to stand up and shout, “Stop it!” She
feels mobilized to assert herself and has a sense of “I don’t deserve this,” “This
is wrong,” and “I’m OK the way I am.” This particular manner of facilitating
deeper experiencing is a central part of interventions used in emotion-focused
therapy (Greenberg & Watson, 2005; Paivio & Pascual-Leone, 2010).
SUMMARY AND CONCLUSION
Working with emotion has been recognized as an integral component

of successful psychotherapy across therapeutic orientations. The underlying
emotional processes that contribute to successful therapy are also not likely to
differ greatly across treatment approaches. However, since the beginning of
humanistic and experiential therapy, the role of emotion has been explicitly
stated and shown to be central to client change. Given this focus, it follows
that practitioners and clinician-researchers from these approaches have pio-
neered many of today’s interventions for working with emotion.
Other approaches to therapy have generally focused on single emotional
processes, such as the cognitive–behavioral emphasis on emotion regulation
or the traditional psychodynamic focus of reflecting on emotion, which have
indeed led to the development of adept interventions for engaging clients in
those specific processes. However, when it comes to working with emotion
in vivo, some of the affective shifts in those treatments were predicated on a
client’s spontaneous experience of hot process or cathartic activation. Thus,
outside the humanistic and experiential tradition, relatively little “technol-
ogy” had been developed to help clinicians increase emotional engagement,
heighten arousal, or purposefully facilitate the transformation of a maladaptive
emotion into another, more adaptive, emotion.
Although specific interventions of this kind are detailed in other chapters
of this volume, a few key research-based strategies include the following: the
importance of deepening client experiencing to facilitate emotional awareness
and engagement (A. Pascual-Leone & Yeryomenko, 2015; Pos et al., 2009);
the pivotal role of promoting emotional arousal in client change, especially in
combination with meaning-making (Missirlian et al., 2005); and promoting
sequences of emotions to bring about emotional transformation (Greenberg,
2002; A. Pascual-Leone & Greenberg, 2007). As one might hope, powerful
strategies such as these for working with emotion have now found their way
back into modern psychodynamic schools and third-generation cognitive
approaches, such that humanistic–experiential interventions have informed
the practice of contemporary treatments at large.

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III
Major Therapeutic
Approaches
6
PERSON-CENTERED THERAPY:
PAST, PRESENT, AND FUTURE
ORIENTATIONS
DAVID MURPHY AND STEPHEN JOSEPH
Since its development by Carl Rogers in the 1940s, client-centered

therapy has been a significant force in the world of humanistic psycho-
therapy. Today the approach, now termed person-centered therapy (P-CT),
continues to evolve to take account of contemporary developments. The
aims of this chapter are to, first, provide an overview of Rogers’s theory and
major concepts related to P-CT and their contemporary use; second, review
the research as to its effectiveness; and third, use case material to illustrate
the application of research to contemporary practice. Finally, after a sum-
mary of the research findings, we provide recommendations for the future
orientations of P-CT.
http://dx.doi.org/10.1037/14775-007
S. Rubin (Editors)
185
OVERVIEW OF THE THEORY
P-CT theory is based on a theory of personality development and behav-

ior that is as prescient to a contemporary view of the person as it was when it
was first developed. The theory of therapy is supported by an extensive body
of empirical research evidence. In the sections that follow, we provide an
outline of the development of the person-centered approach to personality
development and the theory of therapy.
A New Psychotherapy
Twice identified as the most influential therapist in the field of psycho-

therapy (Cain, 2010), Rogers began to cultivate his approach to therapy in
the 1930s. In developing his ideas, he was influenced by Jessie Taft, Virginia
Robinson, and Frederick Allen, students and associates of Otto Rank, whose
approach emphasized the creative forces within the client and the client as
the central figure in the therapeutic process (Ellingham, 2011; Kirschenbaum,
2007). In 1940, Rogers gave a talk at the University of Minnesota in Minneapolis
that was to become the famous “Minnesota speech.” In this talk, titled “Some
Newer Concepts of Psychotherapy,” he began to outline his own approach. In
1942, Rogers published his first major work, titled Counseling and Psychotherapy:
Newer Concepts in Practice, in which he presented a revised and expanded ver-
sion of his 1940 lecture. Rogers referred to his new approach as nondirective
therapy, to describe how the therapist’s task was to reflect feelings and to follow
the client’s lead, thus challenging the therapist-directed and advising style of
the Minnesota school and the interpretive approach of psychoanalysis. A simple
example of an exchange from therapy is given below to illustrate the reflection
of feelings:
Client: I’m so frustrated with myself and everything. I just need to
get out into the town. I’m getting desperate and don’t know
how much more I can take of this, this feeling of being stuck
here.
Therapist: I can see and really hear that this feeling of being stuck
is really getting you down. It’s too much to bear for much
longer.
Client: Right. I need to get out of this place.
Therapist: It’s like you’re saying you really need to get out. Like staying
here just isn’t okay.
The nondirective approach is perhaps best understood as the attitude
embraced by therapists in their attempt to free their clients. Raskin (2005)
186 murphy and joseph

suggested that nondirectivity was not a “matter of acquiring technique, but
of gradually embracing the conviction that people do not have to be guided
into adjustment, but can do it for themselves when accepted” (p. 346).
Nondirectivity has attracted a significant amount of attention in the past
10 years in the field of P-CT. Levitt (2005) suggested that “at its most basic,
nondirectivity implies being responsive to the client’s direction. It implies
that individuals have the capacity and right to direct their own therapy and
lives” (p. i).
Nondirectivity is a complex concept, and views differ on how it best
applies to P-CT. Grant (1990) proposed distinguishing two forms: instrumen-
tal and principled. Instrumental nondirectivity is a pragmatic technique that is
used by therapists. For example, therapists can maintain their nondirective
stance because they believe the client is capable of attaining a therapeutic
goal through self-directed behavior. It is the therapist’s conscious decision to
maintain the nondirective stance, in the belief that this is what is best for the
client, that makes it instrumental. On the basis of a philosophy of pragmatism,
Cain (2013) supported an ethos of “do what is best for the client,” an approach
grounded in the core values of P-CT that remains open to the prospect of
integrating potentially helpful factors from outside the client’s frame of refer-
ence. Similar to this schema, Bohart’s (2012) approach makes a case for the
integration of therapeutic techniques into P-CT. Basing practice on what the
client needs, techniques from other approaches, such as cognitive–behavioral
therapy, can be integrated into the therapeutic relationship. In both of these
approaches, it is apparent how techniques, including nondirectivity, can be
used to serve the development of the client.
Principled nondirectivity implies that the therapist has no intention other
than to create a therapeutic relationship (as defined by Rogers’s, 1957a, six
necessary and sufficient conditions, described below); it is generally consid-
ered to define the classical approach of P-CT. It requires the therapist to trust
in clients’ self-healing capacities, or their right and capacity for self-direction;
as such, it is directly related to the therapist’s ability to offer unconditional
positive regard (Bozarth, 1998; Brodley, 1997).
Principled nondirectivity, therefore, refers not to the behavior but to
the attitude of the therapist. It does not mean that the therapy itself lacks
direction, but that the direction is determined by the client. Grant (1990)
suggested that, from a principled position, the therapist needs to be prepared
to do whatever assists the client. As with the approaches proposed by Cain
(2013) and Bohart (2012), this may involve offering the client techniques
or interventions based on the client’s need at that moment. As such, the
use of various techniques is not counter to even the classical mode of P-CT
(Brodley & Brody, 2011), nor is the offer of responses from outside the client’s
frame of reference (Mearns & Cooper, 2005).
person-centered therapy 187

Although the instrumental–principled distinction proposed by Grant
(1990) has served for many years as a basis for defining P-CT, our view is
that the issue is even more complex than this simple distinction suggests.
Grant acknowledged the place of techniques within the principled position
as being in service to the client. Similarly, Cain (2013) and Bohart (2012)
have argued for the integration of techniques into P-CT on the basis of the
clients’ needs. We suggest that the use of instrumental nondirectivity could
itself be considered one such technique. A dialogue below shows how the issue
might be addressed in therapy with a client. The context is that the client has
expressly requested to be given space to work this one out, and the therapist—
whose stance is that of principled nondirectivity—has respected this request
and has been using instrumental nondirectivity in working with the client.
For the past 15 minutes, the therapist has been closely and empathically
tracking the client, who seems to have become stuck again. This is where we
pick up the session:
Client: I don’t know . . . I really don’t know what to do.
Therapist: Hmmm, you’re really stuck with this . . . can’t see what to do.
Client: Mmm, yes. [Silence for a few minutes]
Therapist: I’m going through some different thoughts right now and
wondering what I can do to help here. One thing I’m very
aware of is that for some time in this session I’ve been closely
following your thinking and feeling in your search for under-
standing.
Client: Yes, I know that was what I asked for.
Therapist: And I’m aware that you said that you really wanted space to
work this one out, and I guess that’s what we’ve been doing . . .
trying to create a space for you to work this out.
Client: Yes, but I don’t seem to be getting far.
Therapist: Okay, well, I am wondering if you still want that space, and
I’m wondering whether or not it might be helpful for me to
share some other thoughts I’m having too. I don’t know if
they’d help, as I’m also unsure if it’s even what you might
want, or if you really would still prefer me to give that space
for you to work this out.
Client: What do you have in mind?
Therapist: I was thinking that there is an exercise that people some-
times find useful in which they use self-talk to learn new
skills, and that we might use that here.

The key issue regarding nondirectivity is whether these interventions
and therapist responses are determined by the client, by the client and
therapist collaboratively, or solely by the therapist. The therapist in this
example is reflecting openly to see what the client needs—an approach
that involves being nondirective, in the sense that the therapist’s inten-
tion remains to track the direction of the client, even if it involves sharing
something from the client’s own frame of reference. The client’s agency is
trusted to be able to respond authentically without being subjected to influ-
ence by the therapist.
Theory of Personality Development
As Rogers (1942, 1951) developed the nondirective approach to ther-

apy, he simultaneously developed a personality theory within which to under-
stand why P-CT would be an effective form of assistance. The theory posits
that the developing infant has an inherent tendency to survive, maintain,
and enhance him- or herself. This core theoretical concept is referred to as
the actualizing tendency. As such, the infant is driven to seek new experiences
and to value those experiences that enhance the organism. This is referred
to as the organismic valuing process. This process is central to Rogers’s (1951)
theory of personality development because it emphasizes the client’s capacity
for self-direction. The client is able to become his or her own expert and to
craft solutions to his or her problems. As development continues, parts of the
total experience of the organism become differentiated, as the self-concept
begins to develop. With the emergence of the self-concept, the infant’s need
for positive regard becomes a potent need in its own right, now separable from
the organismic valuing process.
When the positive regard perceived by children is consistent with their
organismic valuing process, personality development is such that the child’s
unique potentialities are expressed. However, sometimes the organismic
valuing process is at cross-purposes with the self-concept. Psychological mal
adjustment results when there is inconsistency, or incongruence, between the
self-concept and the organismic valuing process (Rogers, 1951, 1959). Greater
incongruence leads to greater psychological tension; the greater the tension,
the greater the psychological distress and dysfunction. Rogers’s theories of per-
sonality development and the actualizing tendency provide the rationale for
P-CT’s nondirective stance. Rogers contended that the actualizing tendency
was inherent in all people—always active, striving toward greater congruence
between the self-concept and experience, and directed toward the develop-
ment, maintenance, and enhancement of the organism.

These principles suggest that the human organism is directional and
can be trusted. Rogers (1957b) described his understanding of a human being
as being basically trustworthy and possessing characteristics
towards development, differentiation, cooperative relationships; whose
life tends to move from dependence to independence; whose impulses
tend naturally to harmonize into a complex and changing pattern of
self-regulation; whose total character is such as to tend to preserve him-
self and his species, and perhaps to move towards its further evolution.
(p. 201)
This radical belief is the key defining feature of P-CT that distinguishes
it from other humanistic experiential therapies.
Conditions of a Helping Relationship and Unitary Source of Distress
In P-CT the six necessary and sufficient conditions (Rogers, 1957a)

that lead to change are that clients and therapists are in psychological con-
tact and that the client is in a state of incongruence and must perceive the
therapist’s unconditional positive regard, empathy, and congruence. These
conditions enable clients once again to learn to trust their organismic valuing
process. As clients grow, the values of others that have been introjected and
made part of their self-concept become less influential in guiding the direc-
tion of their decisions and their course for life. Rather than being governed
by fixed values held within the self-concept, the organism is engaged in a
dynamic process of valuing. The process nature of valuing within the theory
suggests that a person is a fluid and changing system that evolves and emerges
through the interaction of organism and environment.
In Rogers’s (1957a) theory, practitioners do not need a taxonomy of
diagnoses or psychological problems. All forms of distress and dysfunction
that are not biological in origin share this unitary psychological cause of
incongruence. However, distress and dysfunction find a variety of expres-
sions according to the uniqueness of each situation and person (see Joseph
& Worsley, 2005) and therefore might require different things from therapy.
Because psychological distress in all its varieties of expression is thought
to originate from the incongruence between self-concept and experience, there
is no need for specific treatments. It is for this reason that P-CT does not require
training in the use of diagnosis to determine the treatment required. In this way,
P-CT aligns itself with critical psychiatry (Double, 2006), a branch of psychia-
try that sees medicalization of psychological issues as stigmatizing. However,
although P-CT proposes a unitary cause of psychological distress, it requires
therapists to be flexible, creative, and responsive to clients’ needs. There is no
one way to communicate therapist empathy, unconditional positive regard,

and congruence; thus, person-centered therapists must be highly attuned
to the client’s expression and experience in the session.
Contemporary Developments
It is now generally accepted in the field of positive psychology that

Rogers’s (1951) person-centered theory was one of the forerunners of the idea
of positive psychology, with its emphasis on fully functioning behavior (Joseph
& Linley, 2006b; Joseph & Murphy, 2013a, 2013b). Self-determination theory,
developed by Ryan and Deci (2000), provides a more contemporary organis-
mic theory largely synonymous with P-CT. Both the self-determination and
person-centered theories share the basic philosophical position that human
beings are intrinsically motivated toward the actualization of their potential,
but that motivation can be usurped when people do not have their basic psy-
chological needs met, in this case, their needs for autonomy, competence, and
relatedness. Although this is not the only reason people fail to grow, the shared
theoretical ground is ripe for collaboration. Research has shown that, when
basic needs for autonomy, competence, and relatedness are satisfied in relation-
ships, greater well-being results (Patterson & Joseph, 2007; Sheldon, 2013).
Also of importance to the person-centered approach is the observa-
tion that Ryan and Deci’s (2000) conceptualization of need satisfactions is
essentially the same as Rogers’s (1957a) notion of unconditional positive
regard, which supports the autonomy and relationship needs of the client
(see Patterson & Joseph, 2007). Other social psychological research has
provided support for the notion of the organismic valuing process through
the observation that, over time, people tend to move toward more intrinsic
goals (Sheldon, Arndt, & Houser-Marko, 2003); because people are more
intrinsically rather than extrinsically motivated, increased well-being results
(Sheldon, 2013). One contemporary development is positive therapy—the
integration of positive psychology and P-CT—developed by Joseph and
Linley (2006b). In their approach, the therapist is nondirective but always
in support of the client’s autonomy; as such, the therapist may offer and use
exercises from positive psychology to facilitate the client’s direction.
Developments on the Original P-CT Model
Sanders (2012) proposed a number of “tribes” of P-CT: (a) classical

client-centered therapy, (b) focusing-oriented therapy (FOT), (c) emotion-
focused therapy (EFT), (d) integrative P-CT, (e) existential P-CT, and
(f) experiential P-CT. We can also add to these the dialogical–relational
approach proposed by Schmid (2013) and identified by Barrett-Lennard
(2013) as having emerged after the findings of the Wisconsin Project, a large

experimental research study carried out in a hospital setting into the process and
outcome of P-CT with people experiencing psychosis. The dialogical–relational
approach is perhaps positioned under current developments focusing on the
here and now and bidirectional elements of the therapy relationship, including
relational depth and mutuality theory, respectively (see Bazzano, 2014; Knox,
Murphy, Wiggins, & Cooper, 2012; Mearns & Cooper, 2005; Murphy, Cramer,
& Joseph, 2012).
Integrative Approaches
Recently, there has been movement toward integration within P-CT;

however, motivational interviewing (Miller & Rollnick, 1991), which draws
heavily on the principles of P-CT (Csillik, 2013), was proposed by Sanders
(2012) to be only marginally related to P-CT. Other integrative approaches,
such as those proposed by Bohart (2012), M. Cooper and McLeod (2011),
and Cain (2013), have suggested the need for working with the client’s dif-
ficulties in creative ways that aim to be adaptive to the client’s needs. Cain
(2013) contended that integration had the potential to enhance the effec-
tiveness of P-CT by using concepts, methods, and relational styles from other
approaches, thereby enabling the therapist to individualize therapy accord-
ing to what best fit the client’s needs. Each of these integrative approaches
offers something distinct and unique to the development of P-CT. M. Cooper
and McLeod proposed an approach based on the philosophy of pluralism,
which suggests that different people need different things. Their approach
puts the task of identifying client goals as a primary factor, emphasizing that
therapists can be flexible in how they work to help clients achieve thera-
peutic goals.
Bohart’s (2012) approach is based on his previous proposal of the client as
self-healer and as the active primary change agent in therapy. Bohart claimed
that his integration of techniques to support client growth was entirely con-
sistent with the original P-CT model, although he acknowledged that others
in the classical school might disagree. In Bohart’s approach, he drew on the
FOT model as an example of integrating the focusing technique into the P-CT
model, claiming that FOT was a person-centered therapy.
Cain’s (2013) integration was similar to that of Bohart (2012) at the
technical level, although it differed in that it was based on a philosophy of
pragmatism. The approach was grounded in the values of P-CT but carried
out in the belief that things other than therapist acceptance and empathy
could be helpful for a client. In Cain’s form of integration, therapists are
encouraged to share factors external to them, such as making suggestions
that the client is not currently contemplating, and the client remains free to
choose to follow these suggestions or not.

Each of these approaches to integration offers the therapist flexibility,
although some within the classical school might see this as a lapse in discipline
or an infringement on client self-determination. Worsley (2012) offered a view
of integration that suggests that what is integrated is all of life and that the focus
is on therapists bringing their whole self to the therapeutic encounter.
Process-Guiding Approaches
Lietaer (2002) noted that two distinct forms of process-guiding therapies

have evolved: FOT (Gendlin, 1996) and EFT (Greenberg, Rice, & Elliott,
1993). Gendlin (1961) was the first to make a clear departure from the clas-
sical school. His work at the time was concerned with experiencing, which
led him to develop a philosophy and later a therapy now known as FOT. The
approach is based on the ideas of the felt sense and the process of deriving
meaning from direct experience. Rogers’s (1951) work was also concerned
with experiencing, but it was the idea that clients can be directed to focus
on a felt sense that challenged the classical school. FOT has become a widely
practiced, well-respected variation of P-CT. As a tribe, it has many followers
and is clearly a significant development of P-CT.
EFT has emerged over recent years as a significant forerunner in the field of
empirically supported therapies. The approach is based on the person-centered
theory of the primacy of the therapeutic relationship as having a direct impact
on client growth. However, it also emphasizes the role of process-guiding tech-
niques to facilitate the client in achieving greater emotion-processing capacity.
Emotion theory, within this approach, is seen as the primary reason why clients
experience distress. Therapy is focused on supporting the client to transform mal-
adaptive to more adaptive emotion-processing schemes. In EFT, therapists are
typically engaged in one of three response modes, namely, empathic understand-
ing, empathic exploration, or process guiding. The mode of response is related to
the EFT task in which client and therapist are currently engaged. In EFT, there
are empathy-based tasks, relational tasks, experiencing tasks, reprocessing tasks,
and active expression tasks. The therapist uses a range of techniques specifically
selected to assist in achieving the tasks of EFT, which include, but are not con-
fined to, techniques such as chair work from Gestalt–psychodrama approaches
(Perls, 1969), systematic evocative unfolding (Greenberg et al., 1993), building
the therapeutic alliance (Bordin, 1979), and focusing (Gendlin, 1961).
Existential Approach
Rogers’s (1951, 1959) work clearly had an existential influence, and a

number of overlapping features for the classical client-centered and existen-
tial psychotherapies have been proposed (M. Cooper, 2003; Stumm, 2005).

That said, M. Cooper (2012) suggested that, of all the tribes proposed by
Sanders (2012), the existential approach had the most complex relationship
to classical client-centered therapy. A number of features seem to have rel-
evance to both existential therapy and P-CT, namely, the uniqueness of being
in the world, a focus on process, the role of freedom, the human being as direc-
tional and meaning-making, the human being as finite, the inescapable real-
ity of being in relationship with others, the fact that being is embodied, and
the roles of anxiety and authenticity. Although there are many approaches
within the existential school itself, the one that relates most closely to P-CT is
the humanistic–existential approach. Some P-CT therapists have been heavily
influenced by this approach, practiced largely in the United States, and have,
in turn, influenced P-CT (M. Cooper, 2003; Stumm, 2005).
Person-Centered Experiential Approach
There has long been a debate over the differences between person-
centered and experiential therapies. However, a particular tribe that is emerg-
ing in both the United Kingdom and Europe favors a synergistic apprecia-
tion of these two core dimensions, person centeredness and experience. Lietaer
(2002), an early proponent, suggested that these two terms define P-CT. Schmid
(2003) countered, arguing that the difference between person-centered and
experiential therapy exists at the level of the image of a person that each
person holds. Our view is that, rather than see the person-centered and the
experiential therapies as totally separate, person-centered and experiential
dimensions can be considered as two axes on which all tribes could be plot-
ted. A third axis might also possibly be added to represent the level and
style of intervention used by a therapist (Warner, 2000). As we have shown
above, a therapist can be high in terms of intervening while maintaining a
nondirective attitude, although this would mark a clear divergence from the
classical school, wherein nondirectivity refers to both behavior and attitude.
This being said, a person-centered experiential approach accommodates the
potential for integration at the technical (pragmatic) level and acknowl-
edges the experiential dimension to making meaning, but retains the image
of the person proposed in the dialogic–relational school. We believe that this
approach offers one of the most promising potential directions of movement
for future developments in P-CT.
SUMMARY OF RESEARCH FINDINGS TO 2000
The research evidence in this period spans 60 years (1940–2000) and

includes hundreds of published articles. Because space is limited, we have dis-
tilled the evidence presented in a number of previous reviews of the literature

for that period, focusing mostly on outcome research and the effectiveness
of P-CT.
At the University of Ohio in the early 1940s, Rogers pioneered the
development of psychotherapy research by using audio recordings and then
later filming therapeutic consultations. Such data collection was continued at
the Chicago Counseling Center, where Rogers was one of the world’s leading
psychotherapy researchers (Kirschenbaum, 2007). His innovative use of these
new technologies brought psychotherapy to a mass professional and public
audience for the first time. Rogers’s use of the new media led to a period of
process-outcome research that shapes the future of psychotherapy research to
this day.
In the early years (1942–1951), many of the research studies focused on
the role of nondirectivity from the perspective of both process and outcome.
Snyder (1945) found that clients of therapists who maintained a nondirec-
tive approach showed changes in self-understanding, insight, planning, and
positive feelings. In their summary of the research carried out during these
early years, Bozarth, Zimring, and Tausch (2002) concluded that nondirec-
tive counseling was also associated with greater self-exploration, improved
self-concept, and client maturity.
Rogers (1959) provided a summary of the research evidence supporting
the outcomes of P-CT. Among the findings reported were decreases in defen-
siveness (Grummon & John, 1954), changes in perceptions (Jonietz, 1950),
and greater extensionality of perceptions (i.e., seeing the world in differenti-
ated terms and being aware of multiple ways of perceiving and different takes
on reality; Mitchell, 1951). Outcome studies showed greater psychological
adjustment after P-CT, using measures such as the Thematic Apperception
Test, the Rorschach test, and counselor ratings of client change (Cowen &
Combs, 1950; Dymond, 1954; Grummon & John, 1954; Haimowitz & Morris,
1952; Mosak, 1950; Muench, 1947).
Other studies investigated whether P-CT led to an increase in congru-
ence of the self-concept and ideal self and considered changes in the self–ideal
discrepancy (Butler & Haigh, 1950; Hanlon, Hofstaetter, & O’Connor, 1954;
Hartley, 1951; Rudikoff, 1950). Theoretically, a reduction in incongruence is
posited to bring about a reduction in tension, both physiological and psycho-
logical. Two studies supported a reduction in physiological tension (Anderson,
1954; Thetford, 1952), and five studies showed a reduction in psychologi-
cal tension measured by the Discomfort-Relief Quotient (Assum & Levy,
1948; Cofer & Chance, 1950; Kauffman & Raimy, 1949; N. Rogers, 1948;
Zimmerman, 1950). Rogers’s (1959) summary of the research evidence for his
theory also confirmed that nondirective and person-centered therapy lead to
increases in self-regard (Raskin, 1949; Sheerer, 1949) and behavior changes
(Hoffman, 1949; Rogers, 1954).

A number of studies from the late 1950s and 1960s focused on the contri-
bution of therapist attitudinal qualities to client outcome in psychotherapy. A
new psychometric tool, the Relationship Inventory, was developed by Godfrey
Barrett-Lennard. Reviews of psychotherapy research throughout this period
concluded that increases in the therapeutic relationship conditions were asso-
ciated with constructive client outcome (see Bergin & Garfield, 1971; Bergin
& Lambert, 1978/1994; Garfield & Bergin, 1986).
P-CT researchers also carried out studies that examined the effective-
ness of therapy with patients in a psychiatric hospital who had been diag-
nosed with schizophrenia. A study known as the Wisconsin Project (Rogers,
Gendlin, Kiesler, & Truax, 1967) yielded results that were on the whole mini-
mally supportive, although the condition of therapist empathy showed a sig-
nificant relationship to progress. By the mid-1970s, as research interest had
turned from therapist attitudes toward specific client problems, the number
of research studies carried out in the P-CT field declined.
Entering the 1980s, research in P-CT relative to the newly developing
cognitive therapies was notably absent. Despite the wider applications of the
person-centered approach during this time, the research intensity seen in
earlier years dissipated in terms of articles published in peer-reviewed scien-
tific journals. Simultaneously during this period, the ontological framework
driving psychological and psychiatric research changed, as the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders
became increasingly influential.
Whereas the previous 2 decades had provided strong evidence for the
effectiveness of relationship conditions, against the backdrop of the new
question related to which therapies were most effective for which psychiatric
disorders, evidence for P-CT was seen as lacking. Furthermore, little new
research into the question of whether P-CT was effective for specific psychi-
atric disorders was being conducted.
Consequently, throughout the late 1980s and 1990s, P-CT declined
in popularity among psychologists and psychotherapists compared with
cognitive–behavioral therapies (CBTs) that were more inclined to respond
to the demand for evidence in relation to psychiatric diagnoses. In this
changing professional landscape, CBTs were perceived to be grounded in a
firmer evidence base.
Nonetheless, evidence for P-CT continued to build. Smith, Glass, and
Miller (1980) conducted the first meta-analysis of psychotherapy, including a
review of studies of P-CT. One of their main aims was to investigate controlled
effect sizes—that is, to calculate the size of the difference in outcome between
those who received psychotherapy and those who were assigned to a waiting-
list or no-treatment control group. Their study revealed that the difference
between the two groups gave an effect size for P-CT of .62, calculated from

comparing 150 different effects, although the total number of studies from
which effects were taken is not known. An effect size of .62 is considered to
be a moderate effect, where a small effect is considered to be in the region
of .2 and a large effect in the region of .8 (Cohen, 1988).
Greenberg, Elliott, and Lietaer (1994) carried out a later meta-analysis
of outcome studies that was presented in the fourth edition of Bergin and
Garfield’s Handbook of Psychotherapy and Behavior Change. This study reviewed
P-CT in addition to other person-centered experiential therapies, based on
a total of 36 studies involving 1,239 clients. The combined effect size for
pre–post change was reported as 1.20, a seemingly large effect size somewhat
influenced by the larger effects found in EFT. The results may, therefore,
mask the precise effect size for P-CT. In addition, one of the difficulties with
pre–post effect size calculations was the inclusion of studies with just a single
treatment group, making it impossible to attribute the constructive outcomes
to psychotherapy alone. For this to happen, the effects of the psychotherapy
group need to be compared with a no-treatment or waiting-list control group.
Hence, it is possible that these positive results could have occurred by chance.
However, the analysis also reported that the controlled effect size (replicating
the Smith, Glass, & Miller, 1980, statistical procedure) was calculated to be
1.24, a significant increase from the finding of Smith et al. (1980). When the
effect sizes of the P-CT and experiential therapies combined were compared
with CBT, the average difference between therapies was .04, considered by
the authors to be close enough to zero to conclude that there is no significant
difference between the different therapies.
REVIEW OF LITERATURE, 2000–PRESENT
Since 2000, evidence for the effectiveness of P-CT has continued to

build. More recent studies have begun to address the knowledge gap in rela-
tion to diagnostically defined outcomes. Below, we review the outcome evi-
dence for P-CT’s effectiveness, followed by an overview of some of the new
research directions that have developed in this period.
Outcome Research
Meta-analysis continues to be the central source of information for the

ongoing evaluation of randomized controlled trials (RCTs) of psychotherapy.
The statistical and methodological processes used are becoming increasingly
sophisticated and rigorous. In Elliott’s (2002) review, studies were referred to
in broad terms such as the person-centered approach, which included true P-CT
and nondirective supportive therapy (NDST). NDST is an intervention based

on P-CT that has often been used as a control intervention. In some instances,
it was provided by therapists with minimal or no prior training in P-CT and
therefore might be considered a non–bona fide P-CT. However, in other
instances, this was not the case, because NDST was provided by well-trained
therapists and could be considered so close to P-CT that it was indistinguish-
able. Initial analyses showed that the P-CT and NDST therapies were less
efficacious than CBT (ES = -.33). However, Elliott (2002) noted that the
difference was small and possibly the result of researcher allegiance effects or
to the non–bona fide NDSTs that had been added to the P-CT group. Further
analysis showed that, after the NDSTs were taken out of the equation, the
differences between P-CT and CBT remained but were substantially reduced.
A number of large-scale studies have used practice-based evidence.
Stiles, Barkham, Twigg, Mellor-Clark, and Cooper (2006) examined the out-
come of P-CT, psychodynamic therapy, and CBT as they were provided in
naturalistic practice settings in the United Kingdom. Data were collected over
a 3-year period from a large number of clients completing therapy (N = 1,309).
The results were calculated to show the amount of change that clients made
from beginning therapy to termination. Using a statistic known as Cohen’s d
to calculate the overall pre–post effect size, Stiles et al. found broad equiva-
lence across the three approaches. The differences among therapies were not
statistically significant. The effect size for P-CT was d = 1.32, with a 95% CI
of [8.0, 9.4]. For psychodynamic therapy, the effect size was d = 1.23 (95% CI
[6.5, 8.8]). Finally, the effect for CBT was d = 1.27 (95% CI [8.1, 9.7]). A
confidence interval is an estimate of the chance of repeating the same finding
in a similar-sized but independent sample. As can be seen, these results sug-
gested a high level of confidence (95%) for all therapies, including P-CT. The
ranges represent the error, indicating the amount by which one can expect
the scores to vary within the level of confidence that has been set.
Additional reviews during this period assessed the effectiveness of P-CT.
First, Elliott, Greenberg, and Lietaer’s (2004) meta-analysis, published in the
fifth edition of Bergin and Garfield’s Handbook of Psychotherapy and Behavior
Change (Lambert, 2004), reviewed P-CT individually and its comparative
effectiveness vis-à-vis CBT and other humanistic experiential therapies. They
concluded that the differences between the therapies was trivial, whether
looking at RCT or practice-based evidence, and that P-CT continued to stand
up to research scrutiny as a robust approach with a wide range of clients in
psychotherapy.
The second meta-analysis (Elliott, Greenberg, Watson, Timulak, & Freire,
2013) was an updated review for the sixth edition of Bergin and Garfield’s
Handbook of Psychotherapy and Behavior Change (Lambert, 2013). Elliott et al.
(2013) stated that the rate of studies being published on P-CT and, more
broadly, in the humanistic experiential therapy area, had increased to such an

extent that it was now difficult to keep up with developments. Their review
included a total of 195 studies, which added another 77 since the previous
review by Elliott, Greenberg, and Lietaer (2004). The 2013 review covered
studies that had been published over 5 decades, including 123 published dur-
ing the 1990s and the 1st decade of the 2000s alone. This number provides
clear evidence for the revival of quantitative outcome research into P-CT.
The 2013 review was probably the largest analysis of humanistic psycho-
therapies to date, because it included 199 different samples for whom pre–
post effect sizes were calculated, covering therapy with 14,206 clients. The
review covered controlled studies involving 62 comparisons with waiting-list
or no-treatment conditions, from 32 RCTs. Pre–post calculations were made
for 199 different samples, 74 involving P-CT and an additional 33 focusing
on NDST, meaning that more than 50% of the samples tested in the review
came from either P-CT or its low-intensity variant, NDST.
When Elliott et al. (2013) compared NDSTs with CBT, they found them
to be only equivocally less effective than CBT. However, when further inves-
tigations were carried out, Elliott et al. found many of the NDSTs included in
the initial analyses to be non–bona fide treatments. Although these studies
met criteria for inclusion in the meta-analysis, their status as non–bona fide
P-CT is important. Wampold et al. (1997) defined a bona fide treatment as one
delivered by a trained therapist. The therapy must be based on sound psycho-
logical principles and be offered as a viable treatment. Finally, in an RCT,
bona fide treatments must use a manual or contain specified components of
the intervention. Despite the presence of non–bona fide therapies in the anal-
yses, when researcher allegiance was controlled, the weighted effects dropped,
and CBT remained only minimally more effective statistically (-.01; 95%
CI [-.16, .13]). In contrast, when the non–bona fide NDSTs were removed,
true P-CT was reported to be statistically and practically equivalent in effec-
tiveness to CBT. This was the finding across 22 studies inclusive of 17 RCTs
(effect sizes of -.06 for all studies and -.1 for RCTs). Unfortunately, the com-
parison between true P-CT and CBT did not control for researcher allegiance
in the final analysis. In future analyses, it would be helpful if the researchers
reported in the findings a weighted control for researcher allegiance across all
approaches.
Elliott et al. (2013) compared the effectiveness of humanistic–
experiential therapies across two subgroups that were classified as using either
a more or a less process-guiding approach. More process-guiding approaches
were those with active process-guiding techniques such as EFT, FOT, and
Gestalt therapy, and less process-guiding approaches were P-CT and NDST
(the latter, of course, including non–bona fide treatments). The findings
reported effects from nine comparisons, eight of which were with RCTs. The
effect size for the more process-guiding approaches was only trivially better

than that for the less process-guiding approaches, but this finding was not
consistent (n = 9: dw = .14, SE = .18, 95% CI [-.21, .5]), indicating that the
differences in effects between high and low process-guiding approaches was
very small. In fact, when looking at RCTs alone, the findings showed statisti-
cal equivalence (n = 8: dw = .08, SE = .19, 95% CI [-.30, .44]). However, these
results did not control for researcher allegiance, and the majority of trials
were published by researchers closely aligned with the high process-guiding
approaches such as EFT. Consequently, there is a risk of researcher allegiance
in reporting the studies. Despite this caution, Elliott et al.’s review provides
an important set of results offering strong support for the contention that
P-CT has a causal effect on positive client outcome and that nondirective
therapies and high process-guiding approaches show broad equivalence when
compared under trial conditions.
Although most P-CT practitioners do not rely on diagnoses for guiding
the course of therapy, there has been an increase in studies considering the
effects of therapy on clients with specific diagnoses. In Elliott et al.’s (2013)
review, P-CT was compared with other approaches for a range of presenting
problems, including depression, anxiety, relationship and interpersonal diffi-
culties, and medical conditions. P-CT was found to have relatively low effec-
tiveness in the area of anxiety and relationship difficulties. However, the results
with depressed clients reported in two RCTs for postnatal depression were
more promising (P. J. Cooper, Murray, Wilson, & Romaniuk, 2003; Morrell
et al., 2009). The Morrell et al. (2009) trial compared a cognitive–behavioral
approach with a person-centered approach for postnatal depression. Using a
statistical procedure to calculate the chances of having a clinical score of post-
natal depression at 6 months after intervention, they found no statistically sig-
nificant differences between the two approaches. Both cognitive–behavioral
and person-centered approaches were found to be cost-effective, although the
cost of training in the person-centered approach was slightly higher.
Mohr, Boudewyn, Goodkin, Bostrom, and Epstein (2001; Mohr et al.,
2005) compared P-CT in a group format with a cognitive–behavioral approach.
To examine the distribution of scores across a number of mean scores, the
Q statistic was used as a probability score. The results showed no difference
between these group-based interventions (between-groups Q = 1.85, ns;
Elliott et al., 2013).
Elliott et al.’s (2013) review included studies up to 2008; for compari-
sons in the area of depression, it covered 34 samples of clients in 27 studies.
However, in reviewing the literature for this chapter, we also found a system-
atic review of depression in clinical trials comparing NDSTs and another
therapy (usually CBT) with a waiting-list or a no-treatment control, based on
31 studies from well-designed RCTs (Cuijpers et al., 2012). By and large, the
studies did not appear to include true P-CT, based on the criteria described

above and originally proposed by Wampold et al. (1997); however, the precise
extent of this is not entirely clear. Cuijpers et al. (2012) did not seem to have
a clear impression of what P-CT might involve, nor did they make explicit
their methods for meeting a test as a bona fide treatment. Nevertheless, the
results were surprising.
Cuijpers et al. (2012) used a g statistic to calculate the size of the sta-
tistical differences in effects between groups. NDST, when compared with
waiting-list or no-treatment controls, was found to be effective for the treat-
ment of depression (effect size, g = 0.58, 95% CI [0.45, 0.72]). This finding
suggests that, even in the case of therapists with very minimal training in the
principles of P-CT, the approach is effective, only marginally less so than the
CBT carried out in the trial (effect size, g = -0.20, 95% CI [-0.32, -0.08]). It is
important to remember that the CBT in these trials was the target interven-
tion and would have been provided by highly trained and more experienced
practitioners, compared with NDSTs, often offered merely as controls. There
are two interesting points to note. First, Cuijpers et al. (2012) removed two
comparisons of studies of true P-CT and CBT and reran the analyses, finding
that NDSTs maintained a statistically significant effect in the treatment of
depression. Second, the Cuijpers et al. analysis identified several studies that
could be added to the Elliott et al. (2013) review, a number of which were
published after 2008 (n = 7), along with others that were published before
2008 and yet were not listed by Elliott et al. (N = 22).
The findings of studies that have reviewed P-CT and NDSTs suggest they
have an effect broadly equivalent to CBT. Because the only difference between
NDSTs and P-CT seems to be the level of training of the therapists and their
theoretical allegiances, we propose that NDSTs could be considered a low-
intensity form of P-CT. This intervention could be applied when P-CT is not
considered cost-effective, in the same way that low-intensity CBT interventions
are available when high-intensity CBT is not considered cost-effective. The evi-
dence supporting NDSTs is impressive, and the P-CT community could do well
to capitalize on this and draw the attention of policymakers and commissioners
to their utility as a form of P-CT.
New Research Directions
A relatively recent development within P-CT is relational depth (Mearns,

1997; Mearns & Cooper, 2005), a term that describes the moment-by-moment
experience of clients and their therapists and their increasingly congruent com-
munication. During moments of relational depth, client and counselor meet
in “a state of profound contact and engagement” (Mearns & Cooper, 2005,
p. xii). The concept of relational depth resembles Stern’s (2003) moments
of meeting, a concept derived from the earlier work of Pine (1981), which

referred to intense moments within the mother–child relational dyad. Early
life interactions help set down schemata regarding interpersonal relations
and, consequently, are thought in relational depth theory to be healing. In
person-centered theory, relational schemata form part of one’s self-structure,
influencing the capacity to process experience in relationship while recogniz-
ing the other person. Relational depth theory has also drawn from the notion
of I–Thou relating, as was described by Buber (1958).
M. Cooper (2012), in reviewing the research evidence, suggested that
relational depth events were widely reported in P-CT. He also claimed that,
in analogue therapy interactions, clients and therapists seemed to experience
greater relational depth in synchrony with one another. Building on this, M.
Cooper identified four domains of relational depth experiences: self-experiences,
experiences of the other, experiences of the relationship, and experiences of the
moment itself. M. Cooper’s review made the point that, although there were
these distinct elements to meeting at relational depth, some research has sug-
gested a unidimensionality to the experience. Drawing on the work of Wiggins’s
(2011) Relational Depth Inventory, one may conclude that the various ele-
ments of relational depth appear to overlap with one another.
Several studies have found that accounts of relational depth experi-
ences have shown consistency in the subjective phenomenological experi-
ence (M. Cooper, 2005; Knox, 2008; Knox & Cooper, 2010, 2011). Therapist
factors facilitating relational depth were identified by M. Cooper (2012) as
often representing personal characteristics such as being “strong” and “will-
ing to relate at depth” (p. 73). Rogers’ (1957a) core conditions were also
identified as helpful factors, because clients appeared to appreciate an active
therapist who prized the client. Client factors identified referred mainly to
the client’s being ready to meet the therapist at depth and having a height-
ened emotional awareness.
The findings from M. Cooper’s (2012) review supported research from
related fields such as therapist presence (Geller, 2012; Geller & Greenberg,
2002) and mutuality (Murphy, 2010; Murphy & Cramer, 2014; Murphy et al.,
2012). Both therapist presence and mutuality, which are presented by Geller
(2012) and Murphy (2012) as foundations for meeting at relational depth,
warrant further investigation.
Bidirectional and mutual components of P-CT are a central aspect of
relational depth encounters. This conclusion is supported by the development
of the dialogical approach to understanding the relational encounter in P-CT
(Schmid, 2001, 2012). A recent study of mutuality has supported the associa-
tion between the bidirectional nature of the relationship with client progress
(Murphy & Cramer, 2014), and a similar finding is that, in relationships in
which clients experience greater relational depth, better client outcomes were
achieved (Wiggins, Elliott, & Cooper, 2012).

P-CT is an approach grounded in the meta-theoretical assumption of

the tendency toward actualization. With this in mind, we use examples from
therapy to illustrate three practice-related themes. First, we provide an exam-
ple of nondirective empathic responding to highlight the therapist’s role in
supporting the client’s developing autonomy. Second, we provide an example
in which a person-centered therapist integrates a technique to help the cli-
ent gain better control over anxiety and learn to use a relaxation technique.
Third, we draw attention to the contemporary concepts of relational depth
and mutuality, highlighting the intersubjective and bidirectional nature of the
person-centered therapeutic relationship.
Nondirectivity
The client is trying to comprehend difficult and confusing abusive expe-

riences in his childhood. As is common with survivors of traumatic events,
there is often a search for a meaning, for why an event occurred. We join the
session at the point at which the therapist reflects his empathic understanding
of what it is the client has been saying:
Therapist: It just makes no sense to you . . . no matter what you do,
there’s just no sense to it.
Client: I’m not like that, so why were they? Mrs. X, who used to
come into the school, wasn’t like that, so why did they do it?
Therapist: Hmmm, it doesn’t make sense to you, why they did this to
you, yet some other people didn’t. . . .
Client: I know, I’m just no good at recognizing who’s bad and who’s
good, like there’s something wrong with me that I just can’t
see it coming. . . . Well, I can but I can’t.
Therapist: You find it hard to know what to expect from people, like
who’ll treat you good and who won’t.
Client: Yeah, like I . . . I avoid getting close, no matter where, even
if someone in the pub puts their arm around me, I hate it, I
get all [pauses] . . . uncomfortable. You know . . . [long pause]
I call it the stubble effect.
Therapist: The stubble effect?
Client: Yeah, you know, when a bloke’s got stubble on his face . . .
[pauses] . . . It reminds me of being back in the school, when
the dirty bastards are all over you and the stubble scrapes
against ye skin, ye . . . bastards!

Therapist: Like being close reminds you of being back at the school, so
it feels safer to stay away, be on your own.
This exchange illustrates that the therapist does not have an agenda for
how the client should change. The therapist stays within the client’s frame
of reference by reflecting his understanding empathically. The approach is
nondirective, but nonetheless the therapist is active and in deep contact with
the client’s experiencing, moment by moment.
A few sessions later, the client presents some indication of a shift:
Client: People actually like me, I mean, when I walk in the pub,
people say, “Hello, Mac,” and smile. They really seem genu-
inely happy to see me. They don’t want anything from me,
there’s no catch, or at least there doesn’t seem to be, they just
like me for me.
Therapist: It seems like you feel okay around the people you’ve met in
the pub, like you can accept their wanting to know you with-
out having to think too much about what they may want
from you.
Client: That’s right. For the first time, except for here, I can see that
people really like me. They like what they see. I don’t have
to be, be, so much on guard against what’s coming next.
Therapist: It’s like for the first time in your life you’re feeling as though
you can relax when you’re around others, not having to look
out for the danger.
Client: That’s it, but there’s more than that. I mean, it’s like I can
really see that people like me, and that means so much. Like
whatever they did to us in the school and how it made me
grow into that twisted rose, it’s like it’s not like that anymore.
Therapist: So it’s like how you felt about being the twisted rose is some-
how changed by people seeing something they like and
respect.
Client: That’s it, it’s respect. People respect me, and that’s never
been there. I’ve never had that, that respect. There’s always
been a catch.
In the previous section, we proposed that P-CT is based on the radical

ontology that clients are able to self-direct, to know what they need to sup-
port their actualization process. Therapists’ nondirective stance in relation
to clients enables them to learn to trust their organismic valuing again, to
know what they need, and to make choices in their lives consistent with the
emerging congruence between experience and awareness.

Use of Techniques
The nondirective attitude is intended to support the client’s autonomy.

The therapist is, in this case, offering exercises and techniques that may be
helpful to the client in a way that is consistent with the client’s direction, not
that of the therapist, who maintains his or her nondirective attitude.
To illustrate our second practice theme, we now turn to the same client
several sessions later. The client is in a highly anxious state; he has at times
presented some experiences that might be considered psychotic. However,
he also presented on other occasions as anxious, wishing he could “turn off
the machine running” in his head. After some discussion, the client expresses
his desire to be calm and to find a way to relax. As the excerpt shows, the
therapist supports this aspect of his actualizing process and helps him to learn
a self-relaxation method that eventually enables the client to process more
of his trauma.
Therapist: So you just want to have some peace, some quiet from the
machine that’s running in your head?
Client: Yeah, just some peace and quiet. If I can get the program to
stop running for a while, I’ll be able to rest.
Therapist: The program running is exhausting you.
Client: Oh yes, I can’t switch it off, and I can’t sleep when it’s running.
Therapist: Like you want some sleep and the program won’t stop running.
Client: That’s right, I want to relax, but I just can’t get things to slow
down.
Therapist: If you could get things to slow down, that would help to relax
you some.
Client: Yeah, I just want to relax my mind a bit. If I knew how to do
that, it would be great.
Therapist: Knowing how to relax would be really helpful to you.
Client: Yeah, could you help me do that, do you think?
Therapist: You want me to help you relax, and you’re wondering
if I can?
Client: That’s right, can you help me? Teach me how to relax?
Therapist: Well, I’m not sure I can, but if you think it would help to try
and relax you a little, I could try—if you really think that’s
something that would help, to take you through a relaxation
exercise I once learned for myself.

Client: That would really help, I think. I get so overwhelmed with
my thoughts, I just want them to slow down.
Therapist: Okay, let’s try and see how it goes. It seems that you think
that being relaxed will help you slow down and perhaps be
able to get those thoughts to slow down a little.
The therapist then helps the client through the relaxation exercise,
which lasts for about 15 minutes. As the client feels more relaxed and at ease,
the dialogue continues:
Client: Well, I certainly feel calmer now, much more relaxed than
at the start of the session today. Right now I’m wondering
about sharing something that came to me when I was just
sitting back there concentrating on my breathing.
Therapist: Right, so, as you were relaxing, something came up for you,
and now you’re wondering whether or not to share that,
maybe wondering if there’s enough time today and perhaps
whether it’s something you want to get into.
Client: Yeah, well, let me give it a go and see what happens.
Therapist: Okay, give it a go.
Client: Well, as I was just there, relaxed and all that, I started think-
ing about some of those thoughts. But it was kinda differ-
ent. They were coming much slower, and I was able to notice
more things. Fewer thoughts were coming, but I got more
detail to the ones that did come. I was remembering some
stuff from the schools.
Therapist: I see, you want to go on more . . . about the thoughts that
were coming?
Client: I remembered there was someone there for me. It was that
every year or two my dad came to visit me. He couldn’t be
there all the time, I know that. But it made me think that
he hadn’t forgotten us. And till now I’d never really realized
that. I thought we were just dumped in the school and for-
gotten about. But we weren’t.
Therapist: So this came to you right now, for the first time; you can
recall that you weren’t forgotten about, not just dumped and
forgotten. Someone remembered you, and you can remem-
ber being remembered—you were thought about.
It is not uncommon for clients who have experienced trauma to be

highly anxious and unable to regulate their anxiety. This is often fueled by
the need to process memories from traumatic events. When clients request

help to relax, they are indicating a need to rest from attempts to process the
trauma experience. In the excerpt above, the client is communicating his
exhaustion and need for assistance. As the therapist helped the client to
relax, he was able to process more deeply some of his past experiences.
Mutuality and Relational Depth
Although it is difficult to convey through a therapeutic transcript a

moment of meeting at relational depth that captures the mutuality in the
interaction, we think one of the best examples of this kind of relational expe-
rience was captured by Shlien (1967) in his work with Mike, a psychotic
patient. The therapy had been going on for some time. The following is the
account as it was described by Shlien himself:
“I know what that means. The only good thing I ever had [his engage-
ment to a girl] taken away from me, broken up.” He blew his nose,
dropped his handkerchief, and, as he picked it up, glanced at me. He
saw tears in my eye. He offered me the handkerchief, then drew it back
because he knew he had just wiped his nose on it and could feel the
wetness on his hand. We both knew this, each knew the other knew
it; we both understood the feel and the meaning of the handkerchief
(the stickiness and texture, the sympathy of the offering and the embar-
rassment of the withdrawal), and we acknowledged each other and the
interplay of each one’s significance to the other. It is not the tears, but
the exquisite awareness of dual experience that restores consciousness
of self. A self being, the self-concept can change. (p. 164)
This example provides an account of the bidirectionality of the rela-
tionship characteristic of meeting of relational depth. Both Shlien as thera-
pist and Mike as client are aware of each other and have an awareness of
each other’s awareness. This intersubjective empathic attunement, the mutual
congruent experience and acceptance of the other in this moment, are sup-
ported by the relational depth and mutuality research cited above. In this
account, the mutual affective state is quite apparent; however, it does not
show the unfolding of a dialogue in which the client and therapist move
toward a greater depth of relation as the client gradually symbolizes more of
previously denied or distorted experience in awareness.
As an example of this, we selected the following exchange from a tran-
script of Rogers working with the client Mrs. Oak. Rogers (1961) published
the case in his book On Becoming a Person (pp. 93–94):
Client: I have this feeling it isn’t guilt. [Pause. She weeps.] Of course I
mean, I can’t verbalize it yet. [Then with a great rush of emotion]
It’s just being terribly hurt!

Therapist: Mm-hmm. It isn’t guilt except in the sense of being very
much wounded somehow.
Client: [Weeping] It’s—you know, often I’ve been guilty of it myself
but in later years when I’ve heard parents say it to their chil-
dren, “Stop crying,” I’ve had a feeling, a hurt as though, well,
why should they tell them to stop crying? They feel sorry
for themselves, and who can feel more adequately sorry for
himself than the child? Well, that is sort of what—I mean,
as though I mean, I thought that they should let him cry.
And—feel sorry for him too, maybe. In a rather objective
kind of way. Well, that’s—that’s something of the kind of
thing I’ve been experiencing. I mean, now—just right now.
And—in—
Therapist: That catches a little more the flavour of the feeling that it’s
almost as if you’re really weeping for yourself.
Client: Yeah. And again you see there’s conflict. Our culture is
such that—I mean, one doesn’t indulge in self-pity. But this
isn’t—I mean, I feel it doesn’t quite have the connotation.
It may have.
Therapist: Sort of think that there is a cultural objection to feeling sorry
for yourself. And yet you feel the feeling you’re experiencing
isn’t quite what the culture objected to either.
Client: And then of course, I’ve come to—to see and to feel that
over this—see, I’ve covered it up. [Weeps] But I’ve covered it
up with so much bitterness, which in turn I had to cover up.
[Weeping] That’s what I want to get rid of! I almost don’t care
if I hurt.
Therapist: [Softly, and with an empathic tenderness toward the hurt she
is experiencing] You feel that here at the basis of it as you
experience it is a feeling of real tears for yourself. But that
you can’t show, mustn’t show, so that’s been covered by bit-
terness that you don’t like, that you’d like to be rid of. You
almost feel you’d rather absorb the hurt than to—than to
feel the bitterness. [Pause] And what you seem to be saying
quite strongly is, I do hurt, and I’ve tried to cover it up.
Client: I didn’t know it.
Therapist: Mm-hmm. Like a new discovery really.
In this exchange, Rogers and Mrs. Oak gradually deepen their connec-
tion, as Mrs. Oak becomes increasingly aware of a feeling of being hurt, for
the first time, as she gets beneath the layers of her self-concept.

In the summary and conclusion for the first edition of this volume,
Bozarth et al. (2002) titled their chapter “Client-Centered Therapy: Evolution
of a Revolution.” On the basis of the evidence we have reviewed, there is
no doubt of the contribution that this revolutionary approach has made to
contemporary psychotherapy. P-CT continues to offer a therapeutic approach
premised on a revolutionary and radical ontology. Our review of the literature
and extrapolation of research into practice shows that modern understanding
of the nondirective attitude can be helpful to clients even when maintained
by minimally trained therapists such as those involved in NDSTs. Moreover,
when adhered to by highly trained therapists, person-centered therapies can
facilitate the development of a growth-supporting therapeutic environment
with some of the most distressed clients.
The P-CT model now has support not only from the wider field of human-
istic psychology, but also from the growing field of psychological inquiry
evidence from self-determination theory and posttraumatic growth theory,
which lend support for the growth paradigm (Joseph & Linley, 2006a; Ryan &
Deci, 2000). One of the main theories of posttraumatic growth now attract-
ing research and clinical attention is an explicit integration of the person-
centered approach with trauma theories (Joseph & Linley, 2005). There is a
need for practitioners and scholars in the field of P-CT to engage more fully
with the mainstream field of psychology and the new developments that build
on and are consistent with the person-centered approach (Joseph & Murphy,
2013a, 2013b).
Although the person-centered approach has seen a reduction in avail-
ability in the United States and to some extent in part of northern Europe,
in the United Kingdom the approach remains strong. In fact, P-CT is one
of the most widely available approaches found in training courses. The
National Health Service and the National Institute for Clinical Excellence
have recently supported the development of an integrated version of P-CT
for depression. Called counseling for depression (Sanders & Hill, 2014), the
approach is now supported as an evidence-based therapy and is offered as a
high-intensity therapy and credible alternative to CBT. The increase in out-
come research studies reported in the meta-analyses reviewed in this chapter
suggests that research on the approach is in a state of revival. This is in large
part attributable to the evolution and integration of classical and experien-
tial theories and practices. In our own training program at the University of
Nottingham, we have taken the step to name the course Person-Centered
Experiential Counseling and Psychotherapy, highlighting the fusion of these
two core dimensions to the approach. We see this direction of movement
in the field as the logical position for P-CT to take. Although our staff have

diverse theoretical backgrounds, we have found ways to coalesce around the
basic ideas of intrinsic motivation for growth and an experiential relationship
between therapist and client.
For the training of therapists in the future, we recommend that courses
focus on three aspects in particular. First is the development of unconditional
positive self-regard and the congruence of the therapist. Second is a thorough
understanding of the concept of nondirectivity in the therapeutic relationship.
Third is that trainees in P-CT undertake study in areas that extend beyond
their understanding of individuals and their internal functioning, so that they
can look at the social world through the lenses of social psychology, positive
psychology, sociology, anthropology, and cultural studies. Rogers (1980) indi-
cated this need to take a wider view, although it seems almost to have been
forgotten. We suggest that, in a time at which our world is affected by war and
terror, by climate change and natural disaster on an ever-increasing scale, our
understanding of the interconnectedness of human activity is essential.
In this light, we end with some thoughts about the future of P-CT. We
believe, based on the evidence reviewed above, that this is an exciting time to
be a person-centered therapist. The quantitative evidence is building, and the
approach has repeatedly stood up well against other approaches—both more
process-guiding humanistic therapies and those outside humanistic approaches
such as CBT and psychodynamic therapies. We also think that sufficiently
supportive evidence exists for low-intensity P-CT that can be referred to as
NDST. Building on this, it is possible to envisage how, in the not-too-distant
future, P-CT will sit alongside other therapies supported by policymakers and
treatment guidelines. Some of the strongest evidence for this is found in the
United Kingdom through the counseling for depression initiative.
It is likely that, as we understand in greater depth the intricacies of
person-centered theory, including the role and place of nondirectivity in
contemporary practice and its capacity to hold the integration of techniques,
the distinction between person-centered and experiential therapies will
diminish. For the future, we envisage a person-centered experiential therapy
that offers a flexible, effective, and evidence-based therapy that is widely
available. We believe this is the natural direction of movement in terms of
both theoretical development (relational depth and mutuality) and practice
(through the increasing number of integrationist expressions).
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7
CONTEMPORARY GESTALT THERAPY
PHILIP BROWNELL
Gordon Wheeler (Lobb & Wheeler, 2013) described the focus of Gestalt
therapy as understanding the processes and structures by which human beings
organize and interpret their perceived worlds, that is, a process of discovery.
It is a hermeneutic and phenomenological perspective achieved in the course
of Gestalt therapy through the relationship between therapist and client in
the midst of a complex situation.
In this chapter, I provide a theoretical overview of the core theory of con-
temporary Gestalt therapy. It has come a long way since the days of Frederick
and Laura Perls, who focused on the revision of psychoanalysis (Perls, 1947/1969)
in an early theoretical integration of existential, phenomenological, and organ-
ismic theories (Brownell, 2010; Perls, Hefferline, & Goodman, 1951/1972).
Since then, classical Gestalt therapy’s pragmatic roots have developed into a
grounded faith in process. Its phenomenological roots evolved from aware-
ness of current experience to appreciation for embodied cognition (Frank &
http://dx.doi.org/10.1037/14775-008
S. Rubin (Editors)
219
La Barre, 2011; M. Johnson, 2007) and the interpretation of experience
(Gallagher & Zahavi, 2008). Its emphasis on contacting, the meeting of the
organism at the boundary with others in the environmental field, became both
an enriched understanding of relationship and a more complex understand-
ing of causation in the organism–environment field itself. The field theory of
Kurt Lewin and others became refined in the understanding of intersubjective
processes occurring in groups, societies, and cultures. The experiential aspects
of Gestalt therapy matured into an understanding of kinesthetic processes at
the base of primordial experience (Frank, 2001).
GESTALT THERAPY AS AN INTEGRATIVE APPROACH
As Gestalt therapy emerged in the middle of the last century, it became

identified with humanistic psychology; however, it is apparent that Gestalt
therapy actually formed as an early case of theoretical integration, which
is more than a technical blend of methods—it is a conceptual framework
and a synthesis of theories or approaches that is more than the sum of its
parts (Norcross, 2005). The question in such an integration concerns how
far it goes. Does it, for instance, extend to a common anthropology, theories
of personality and psychopathology, worldviews, or epistemological commit-
ments (Lampropoulos, 2001)? Theoretical integration of otherwise disparate
approaches requires some kind of organizing center—an attractor that draws
the parts together, holding them in place and guiding the extent to which the
integration reaches. The organizing center for the integration that became
Gestalt therapy is its anthropology—the concept of the person as emerging
from the organism–environment field through contacting. That is, the human
being in early Gestalt therapy was conceived of as an organism–environment
entity, not just an organism in an environment.
THEORETICAL OVERVIEW
The options available to a Gestalt therapist are derived from the four
main tenets of its theory, unified in a process of contacting in the therapist–
client field. That process illuminates the patterns and sequences people use to
make meaning. The therapist can (a) follow the emerging experience of the
client through a modified phenomenological method, (b) engage the client
through dialogue, (c) strategically address aspects of the field, and (d) nego-
tiate an experiment—a move to enactment in the service of awareness and
learning (Brownell, 2008; Mackewn, 1997).
220 philip brownell

Modified Phenomenological Method
The modified phenomenological method used in Gestalt therapy is an

adaptation of Edmund Husserl’s philosophical method. It has the rule of epoché,
the rule of description, and the rule of horizontalization (Spinelli, 2005), a philo-
sophical method that is adapted for a psychological purpose (Giorgi & Giorgi,
2003). In the rule of epoché, therapists set aside initial biases and suspend
assumptions and expectations to pay attention to what is unfolding in their
presence. In the rule of description, the therapist describes what is observed
rather than explaining it. The rule of description avoids premature modeling
to gather as much as possible of the available information. In the rule of hori-
zontalization (also referred to as the rule of equalization), the therapist treats all
observed data with equal importance and without assigning value or structur-
ing a hierarchy. For the therapist, these rules can be synthesized in the proce-
dural dictum: “Observe, bracket, describe.”
Phenomenology is the logos of phenomena, the study of how things
appear to a conscious subject (Spinelli, 2005). Because a phenomenon is an
appearing (arising from the Greek phainō, a verb form meaning “to appear”),
then the method used in studying that phenomenon is a showing. One can
explain the theory of chess or one can simply show someone how one plays
the game (Hass, 2008). In Gestalt therapy, the therapist is in the process of
showing the client to the client (i.e., showing the client how the client plays
the game of life), bringing to the client’s awareness, in various ways, the what
and the how of the client’s appearing.1 This phenomenological work is the
focus of concern for the Gestalt therapist. It is the therapist’s tracking of the
“aboutness” of experience, the unfolding subjective awareness of events and
the meanings given to any particular aspect of that experience by the client.
Dialogical Relationship
The relationship between therapist and client in Gestalt therapy is often

referred to as a dialogical relationship. This is because Gestalt therapy bor-
rowed significantly from the relational philosophy of Martin Buber (Buber,
1923/1958; Mann, 2010). Buber proposed two modalities of relating: I–It and
I–Thou. The I–Thou modality is the primary construct for personal relation-
ships, for knowing and being known by another, and it points like an icon2 to
the meeting between one subject and another. It is characterized by mutuality,
1
This same focus has often been attributed to the influence of Taoism and Buddhism in the formation
of Gestalt therapy, with their respective interests in awareness in the current moment and the way in
which any given thing is taking place.
2
An icon points to something more significant beyond itself and is in contrast to an idol, which points
to itself as that which is of most importance.
contemporary gestalt therapy 221

directness, and presence. This personal connecting can exist between per-
sons, between humans and animals, and between humans and God (Brownell,
2012; Friedman, 2002). The I–It modality is the primary construct for expe-
riencing and using, for getting business done; it is goal directed, pointing to a
meeting between a subject and an object of utility.
Both I–It and I–Thou can be seen in relationships, and it is helpful to
realize that there are different kinds of relationships. When I am in contact
with the world, a meeting takes place, and if I am routinely in such contact
with the same things, places, or persons, then I will establish some kind of
relationship with those things, places, and persons, because relationship can
be understood as contact over time (Yontef & Bar-Joseph Levine, 2008).
Consequently, there are different kinds of relationships and various degrees
of depth and complexity that describe them, with the nature of those vari-
ous relationships linked to the field conditions, the contexts, in which such
meetings take place.
The therapeutic relationship in Gestalt therapy contains elements of I–It
as well as I–Thou. Therapists conduct mental status evaluations (in one way or
another) because they must understand what they are dealing with and what
kind of professional response is called for. They create treatment plans. They
must attend to issues related to informed consent and payment for services.
“In I–It relating we are objectifying, goal oriented, concerned with doing
rather than being. The task becomes figural whilst the other recedes into the
ground” (Mann, 2010, p. 175).
The relationship between therapist and client in Gestalt therapy is non-
independent in nature (Kenny, Kashy, & Cook, 2006); the therapeutic actions
of the therapist arise from the meeting of the two subjects—therapist and
client—and the embodied postures and enactments emerging between them
provide a primordial discourse that is read neurologically and consciously
understood hermeneutically (Ginot, 2009; Ziv-Beiman, 2013). It is primor-
dial because it is preverbal. It is read neurologically as embodied cognition, as
in the action of mirror neurons. It is understood hermeneutically through the
interpretation of experience.
In terms of this relationship with an emphasis on therapist presence,
Geller and Greenberg (2012) wrote,
Therapeutic presence is the state of having one’s whole self in the encoun-
ter with a client by being completely in the moment on a multiplicity of
levels—physically, emotionally, cognitively, and spiritually. Therapeutic
presence involves being in contact with one’s integrated and healthy self,
while being open and receptive to what is poignant in the moment and
immersed in it, with a larger sense of spaciousness and expansion of aware-
ness and perception. This grounded, immersed, and expanded awareness
occurs with the intention of being with and for the client, in service of his
222 philip brownell

or her healing process. . . . Being fully present then allows for an attuned
responsiveness that is based on a kinesthetic and emotional sensing of
the other’s affect and experience as well as one’s own intuition and skill
and the relationship between them. (p. 7)
Gestalt therapists attempt to support the development of a dialogical rela-
tionship by practicing presence and inclusion. Inclusion encompasses empathy
in that it is a throwing of the self on the part of the therapist as much as possible
into the experience of the client (Yontef & Fuhr, 2005). It is the attempt to
open up the mystery of the client’s subjective experience (Staemmler, 2012).
Field Theoretical Strategies
Gestalt therapy is a field theoretical perspective. It is a system of dynam-

ics in which the experience of the person is a result of awareness of the
organism–environment boundary (me–not me; self–other). This boundary
develops from the thinking of two German scientists—Kurt Goldstein and
Kurt Lewin. Goldstein (1995) indicated that one could not understand the
neurological reflex arc3 outside the brain in which it occurred, nor could
one understand the functioning of the whole brain outside the person in
whom it was located or the person outside the context in which that person
lived. Lewin (1943, 1951, 1999) investigated the causative relationships
between factors in the field, pointing to the scientific method in the work
of Galileo, who examined the way things worked together, as opposed to
the philosophical approach of Aristotle, which was focused on the nature of
things themselves. Because of Goldstein and Lewin, it is not a stretch to view
Gestalt therapy as an application of clinical neuropsychology (Philippson,
2012) on the one hand and of social psychology on the other—the brain sci-
ence behind individual experience and the study of people in groups (Archer,
1982; Elder-Vass, 2007).
Understanding the field in Gestalt therapy is a mix of two ways of con-
templating this construct (O’Neill & Gaffney, 2008). The field is at once the
subjective experience of a system and the action of the system itself.4 This
implies the ontic primacy of phenomena—that is, we are in touch with things
and people that actually exist in a world and that are not simply our represen-
tations, our subjective constructions concerning them (Carman, 2006/2007).
The phenomenologist Maurice Merleau-Ponty, for instance, conceived of the
lived body as a phenomenon to include both the immanent agency of con-
scious life and the transcendent world of objects (Dillon, 1988/1997)—that
3A reflex arc is a neural pathway that controls an action reflex.

4System is too limiting a construct, but it is similar enough at this point for the sake of illustration.

is, the ability of persons to create their own experiences and the pushback
from a world that exists outside of any given person’s thoughts about it. The
field consists of both subjective needs and objective press.
The field is all things having effect; thus, it concerns questions of
causation. Fields are overlapping spheres of influence (Crocker, 1999). They
are also complex, adapting systems—dynamic systems and environmental
structures such as cultures and societies, weather fronts, ecologies, or inter-
connected economies. Thus, the field can be conceived of as a phenomenal
field (pointing to the subjective organization of the processes of contacting)
and an ontic field (pointing to the impact of a sphere of influence that exists
outside anyone’s subjective organization of it).
Robert Stolorow (2011) pointed to the connection among the phe-
nomenal field, the ontic field, and the emergent sense of self, describing
Heidegger’s conception of the structure of affectivity as consisting of “both
how one feels and the situation within which one is feeling, a felt sense of
oneself in a situation” (p. 25).
Existential Experimentalism
Theoretical knowledge is made tangible through experience; imagina-

tions are rejected or confirmed experientially. Dramatic and emotionally illu-
minating results often erupt as a result of moving from talking about something
that happened outside the therapeutic session to exploring the experience of
the client in the current moment. This can be accomplished through phe-
nomenological inquiry and dialogue, but it can also be done using experiment,
which is often much more vivid.
Enactment in this context is a move to action. A supervisor might say,
“Be your client.” A therapist might say, “Be your husband.” Enactment is a
“be-ing,” an embodied expression of what one senses in another, what one
feels in oneself, what one fears in the future, and so forth. Such enactment
allows implicit life patterns to be experienced within the therapeutic process.
It enables both therapist and client to attain an unmediated connection with
what cannot yet be verbalized. This is significant because a “growing body
of clinical work and neuroscientific research has demonstrated that what
enactments communicate in such gripping and indirect ways are implicit,
neurally encoded affective and relational patterns. Patterns formed before
verbal memory was fully developed” (Ginot, 2009, p. 294).
The enactment of experiment is not a technique. A technique is a rigid
procedure that is fixed in form and used over and over. It is a prefabricated
exercise, bottled like medication and waiting in the therapist’s cabinet, to be
taken out and given to the client in a certain dosing regimen to bring about a
state or lead the client to a preconceived result (Roubal, 2009). In contrast,
224 philip brownell

an experiment is an embodied move to enactment in the service of increased
awareness and learning.
Experiments are also existential leaps of faith, because one does not
know how things will turn out. Indeed, the purpose of an experiment is to
find out what might happen and to notice just how things do turn out. This
relies on faith, which is critical to the experimental process. In the worldview
of the founders of Gestalt therapy, faith was conceived as “knowing, beyond
awareness, that if one takes a step there will be ground underfoot; one gives
oneself unhesitatingly to the act, one has faith that the background will pro-
duce the means” (Perls et al., 1951/1972, p. 343). Thus, in Gestalt therapy
faith becomes an instrument of knowing and an essential, supporting principle
of contact.
For example, in working with couples I often ask the couple to interact,
to look at one another, to engage one another in some way. While working in
a community resource center for children and families, I began working with
a man and his wife. She was frustrated with his emotionless way of attending
to facts and trying to “fix” her concerns. While we were talking about these
things, I noticed the muscles contracting at the corners of his jaw.
I said, “Touch the side of your face right here” (indicating where I saw
his muscles contracting). He touched that place, and I said, “Now talk from
that place.”
“I don’t see what the big deal is,” he started to say, talking from that place
(but, as he continued talking, his throat became constricted and his voice took
on a whisper, heavy with emotion. It became difficult for him to speak).
I turned to the wife and said, “What do you hear?”
She replied, “He’s feeling something,” and started laughing.
Beyond the scope of specific experiments, the entire Gestalt therapeutic
process can be considered experimental. Perls et al. (1951/1972) claimed that
psychotherapy “is a process of experimental life-situations that are venture-
some as explorations of the dark and disconnected, yet are at the same time
safe, so that the deliberate attitude may be relaxed” (p. 266).
Intrinsic to the existential experimentalism of Gestalt therapy is Gestalt’s
paradoxical theory of change. Beisser (1970) asserted that change occurs when
one becomes what one is, but not when one tries to become what one is not.
Change cannot be coerced through attempts by the client or efforts by therapist
to cause it; rather, change takes place when a person is invested in actualizing
an authentic self in the current, situated moment. Thus, change will take care
of itself if one trusts in the process.
Experiments in Gestalt therapy are multitudinous in that they are novel
creations arising from the flow between therapist and client. However, they
do fall into some familiar categories. Experiments include augmentation,
imagination, and diminishment (Brownell, 2010; Kim & Daniels, 2008).

These kinds of experiments are also examples of high-process guiding (as
compared with relatively low-process guiding as in person-centered therapy);
Lambert (2013) and his colleagues have established that high-process guid-
ing approaches such as emotion-focused and Gestalt therapies show larger
effect sizes in various meta-studies. Process guiding refers to the activities of
the therapist in directing therapeutic sequence, pointing out qualities and
aspects of that process to the client, calling the client to focused attention,
inviting the client to action, and so forth.
A Cohesive Unity in Practice
The meeting between therapist and client takes place in a context that is
at once physical, material, phenomenal, and relational. Both client and thera-
pist bring something to their meeting from outside the context of therapy.
Both of them assimilate from this meeting what they can and reject what they
cannot; it is the creative adjustment they make in the process of their meeting
(Bandín, 2012).
Contacting is the best term for this meeting, because it is a process and
not a static event. Contacting takes place between persons, but it also takes
place between any given person and the environment. This contacting,
including the sensory quality or nature of it—what some in Gestalt therapy
call an aesthetic criteria5 (Bloom, 2003, 2011)—is a center of gravity that pulls
together the core of Gestalt therapeutic practice into one, unified, approach.
In Gestalt therapy, all the various core tenets are active simultaneously.
It is not simply multimodal. The phenomenological method of tracking the
emerging experience of the client, the dialogical relationship in which each
grows in experiential knowledge of one another, the field-theoretic strate-
gies in which causative influences are both understood and initiated, and the
experimentalism in which both client and therapist move to enactment are
all in play at the same time, during the very first meeting between therapist
and client.
SUMMARY OF RESEARCH, 1940–2000
When Gestalt therapy formed in the middle of the last century, its
founders were not interested in research. In spite of this, over time scattered
research was conducted in a few places, and studies of one kind or another
were reported in the first edition of this book. Strümpfel and Goldman (2002)
5
The word aesthetic refers to the senses, so in this context it is about what can be known through the
senses, through meeting others and the environment.
226 philip brownell

referred to numerous examples of using chair work, because the use of the term
Gestalt was evident as a technique in the studies they chose. For instance,
W. R. Johnson and Smith (1997), who studied the use of Gestalt therapy in
the treatment of phobias, divided their subjects into three groups (Gestalt
empty-chair dialogues, systematic desensitization, and no treatment). They
found that empty chair and desensitization worked equally as well as no
treatment (Melnick, 2013). Aspects of Gestalt therapy such as chair work
have been woven together to form other approaches, and such hybrids using
Gestalt techniques are ubiquitous. Chair work, whether that be empty
chair or two chair, has at this point been widely supported by research
and scholarship connected with Gestalt therapy, emotion-focused therapy
and process–experiential therapy, redecision therapy, cognitive–behavioral
therapy (CBT), and schema therapy (Kellogg, 2004; Kramer & Pascual-
Leone, 2013).
Gestalt therapy has also been supported through investigations of
humanistic psychotherapy. For example, Elliott and Hendricks (2013)
offered an online list of 19 abstracts briefly depicting research that described
Gestalt-oriented growth groups, phenomenological explorations of experi-
ence, and use of Gestalt techniques in various quasi-research designs. The
studies established a general impression of the value of Gestalt therapy in
dealing with various subjects. For instance, Beutler et al. (1991) found that
Gestalt-influenced experiential therapy was especially consistent in treating
externalizing and internalizing depressed patients, with moderately positive
results for both. Of importance in Beutler’s studies using a manualized version
of Gestalt therapy was the observation that effect sizes increase over time
after the end of therapy, which is an advantage over CBT (by comparison;
Melnick, 2013).
Ryan and O’Leary (2000) conducted an outcome study of Roman
Catholic seminarians based on randomized groups (treatment and control)
using 20 hours of Gestalt group work to investigate acceptance of self and
of others. The study was an exploratory project of the effectiveness of
“I” statements in Gestalt therapy, which verbally express observed bodily
phenomena. It used a 7-month follow-up, quantitative assessment (analyses
of covariance, t tests) and qualitative assessment (content analysis). Gestalt
therapy was shown to be effective for older seminarians. In another exam-
ple, follow-up research using the model of Seligman’s Consumer Reports
study was conducted (Strümpfel & Goldman, 2002) to show that 73% of
the clients had strong to mid-level improvement in a diversity of symptoms
and problems and were pleased with the results. As a general observation,
extensive research for several decades now has substantiated an equiva-
lence between the outcomes of humanistic–experiential psychotherapy and
other approaches, including CBT.

REVIEW OF RESEARCH 2000–PRESENT
In this section, I examine more current research, including research

trends, and I do so in four parts, using the categories of Gestalt-specific
research, Gestalt hybrid research, Gestalt consilient research, and trends in
the developing Gestalt therapy research tradition. Gestalt-specific research
includes research that is focused on the practice of Gestalt therapy as described
above, not simply research on approaches that use Gestalt techniques but
actually remain something other than Gestalt therapy; that is covered under
Gestalt hybrid research. In the Gestalt-Consilient Research section, I exam-
ine research relevant to the Gestalt approach because major features of some
other clinical theory and practice so closely resemble Gestalt therapy in some
way as to make that research applicable to the Gestalt approach as well.
The last section concerns the increasing development of a Gestalt therapy
research tradition.
Gestalt-Specific Research
Stevens, Stringfellow, Wakelin, and Waring (2011) reported on a 3-year

quantitative outcomes study conducted in the United Kingdom that showed
Gestalt therapists were as effective nationally as clinicians using other thera-
peutic approaches. They used the Clinical Outcomes in Routine Evaluation
(CORE) instrument. The CORE database, widely used in the National Health
Service in England by therapists from a wide variety of clinical perspectives,
contained data for 50,000 clients at the time of the study’s publication. CORE
involves a self-report questionnaire filled in by the client at the beginning and
end of therapy. It also includes assessment and end-of-therapy forms completed
by the therapist. The 34 items cover four dimensions: subjective well-being,
problems or symptoms, life functioning, and risk or harm. The scores from the
questionnaire are averaged to give a mean score to indicate current level of
psychological distress, ranging from healthy to severe. The comparison of pretest
and posttest scores offers a measure of outcome—whether the level of distress
has changed and by how much. The system is designed to be completed for
each client by each practitioner in a service, thus providing comprehensive
profiling rather than focusing only on the clients likely to do well.
Gestalt therapists in both the public and private sector participated in
the Stevens et al. (2011) study, and data for 180 Gestalt clients, largely in
their 30s and 40s, were included. About 22% had anxiety, 18% had depression
or interpersonal relationship difficulties, 11% had self-esteem difficulties, and
the rest presented with bereavement, work or academic issues, physical prob-
lems, trauma or abuse, personality issues, primary support, addictions, eating
disorders, or psychosis. Most (81%) were seen weekly, with 91% attendance.
228 philip brownell

The overall results for cognitive–behavioral, person-centered, and psy-
chodynamic approaches were equivalent in this large study, and the results for
Gestalt therapy were comparable (Stevens et al., 2011). The study indicated
that clients in the Gestalt cohort started off slightly more distressed than
those in the benchmark and comparison cohorts (CBT, person centered, and
psychodynamic). The pre–post mean difference for the benchmark group was
9.0; pre–post mean differences were 8.8 and 8.9 for the comparison cohorts
and 8.4 for the Gestalt group. The effect size for the benchmark cohort was
1.42, with the effect sizes of 1.36 and 1.39 for the comparison cohorts and 1.12
for the Gestalt group. Using a separate metric, the study examined for reliable,
clinically significant improvement; in that regard, 53.8% of the benchmark
group showed improvement; the comparison cohorts had 58.3% and 61%,
respectively; and the Gestalt cohort had 56.3%. Thus, Gestalt therapy was
seen to be roughly equivalent in effectiveness to the therapeutic approaches
widely used in the National Health Service in England, which consisted of
cognitive–behavioral, person-centered, and psychodynamic therapies.
Yousefi et al. (2009) compared the effectiveness of logotherapy with
Gestalt therapy for the treatment of anxiety, depression, and aggression.
Ninety students referred to the student counseling center at Islamic Azad
University of Mahabad in Iran were randomly assigned to an experimental
group for logotherapy, a group for Gestalt therapy, or a control group, with
30 in each group. The experimental groups received Gestalt and logotherapy
for 12 one-hour sessions. Students were evaluated before any treatment using
a symptom checklist and a diagnostic interview based on the Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric
Association, 2000). They were also evaluated at the end of therapy and then
6 months after treatment concluded. No significant difference was found
among the pretest means for the three different groups; however, the treat-
ment groups using Gestalt and logotherapy were both found to have reduced
symptoms for aggression and anxiety, a reduction that was still observable
at the 6-month follow-up. Logotherapy showed an advantage over Gestalt
therapy in the treatment of depression.
Saadati and Lashani (2013) conducted a study randomly assigning
34 divorced women to a treatment group and a control group. The treatment
consisted of Gestalt therapy using traditional Gestalt techniques such as the
empty seat, assuming responsibility, and attending to unfinished business. They
used Sherer et al.’s (1982) General Self-Efficacy Scale in pre- and posttesting to
assess the effectiveness of the Gestalt intervention for increasing general and
social self-efficacy in women who usually suffer losses in self-esteem and con-
fident self-regulation after divorce. The pretest means were 46.17 (SD = 4.9)
for the experimental group and 46.18 (SD = 3.94) for the control group. The
posttest mean for the experimental group was 5.82 (SD = 4.21), whereas that

for the control group was 45.64 (SD = 3.95). The researchers concluded that
the use of Gestalt therapy significantly (p < .001) raised the divorced women’s
self-efficacy.
In an uncontrolled effectiveness study conducted among mental health
professionals in Hong Kong to evaluate the effect of Gestalt therapy with regard
to emotional well-being and hope, Man Leung, Ki Leung, and Tuen Ng (2013)
found that subjects had a significant decrease in anxiety and depression and a
significant increase in agency and hope pathways. This study was also related
to the issue of self-efficacy through the construct of hope. Researchers used the
State Hope Scale (Feldman & Snyder, 2000), which has two dimensions: sense
of agency and hope pathways to meet one’s goals. Sense of agency involves a
belief in one’s capacity to initiate and maintain action with reference to a goal,
and hope pathways relate to the ability to generate alternative ways to achieve
a goal. Both of these would be related to one’s sense of self-efficacy and self-
regulation, an important construct in Gestalt therapy.
In this study, Man Leung et al. (2013) also used the Hospital Anxiety
and Depression Scale (Bjelland, Dahl, Haug, & Neckelmann, 2002) to assess
the presence and levels of apprehension and gloominess. Fifty-five partic-
ipants were asked to fill out these instruments before participating in the
Gestalt intervention and then again after it. The Gestalt intervention was
aimed at developing participants’ awareness of the current moment (the “here
and now” of subjective experience), and all sensory modes were addressed
through an interactional and experiential group process that also fostered
dialogue among group members. Paired t tests were conducted to compare
subjects’ scores for anxiety, depression, hope agency, and hope pathways. Man
Leung et al. found a statistically significant decrease in anxiety, t(54) = 5.41,
p <.001, d = 0.73, and depression, t(54) = 2.88, p <.01, d = 0.39, from pre- to
posttest. They also found a statistically significant increase in both agency,
t(54) = -6.71, p <.001, d = 0.90, and hope pathways, t(54) = -5.93, p <.001,
d = 0.79. In addition, qualitatively the researchers observed a high level of
participation among participants, which they attributed to the care given to
before contact (the developing of contacting) that was built into the aware-
ness, experiential, and dialogical elements of the Gestalt intervention. This
was culturally relevant, because the researchers noted that Chinese people
are “face sensitive” and reluctant to disclose vulnerabilities and past hurts in
front of strangers.
Kelly and Howie (2011) used narrative inquiry and analysis to explore
the influence of Gestalt therapy training on the practice of psychiatric nurses.
Four registered psychiatric nurses in Victoria, Australia, were chosen for this
qualitative approach; they came from adolescent mental health services,
specialty mental health services, education and professional development,
and private practice. Data were collected through semistructured, individual
230 philip brownell

narrative interviews involving reduction, synthesis, and reconfiguration to
produce stories for the research outcome. A thematic analysis across the sto-
ried database was conducted, involving the systematic, rigorous, and careful
examination of the plots and subplots featured in all stories to identify com-
mon elements and experiences across the stories.
Kelly and Howie (2011) developed a synthesis of these plots and subplots
to inform eight emerging themes: growing professionally in fertile ground,
resonating with the Gestalt potential, emerging Gestalt potential in psychiatric
nursing settings, Gestalt learning: the self in process, bringing Gestalt into psy-
chiatric nursing practice, expressing the multidimensional influence of Gestalt
therapy on advanced psychiatric nursing practice, integrating and assimilat-
ing Gestalt, and making sense. The study supported a congruence between
the philosophical values of Gestalt therapy and core psychiatric nursing—the
value of Gestalt therapy training to holistic person-centered, psychiatric nurs-
ing practice—as mapped on the Gestalt cycle of experience. It showed a pro-
gression in the development of nurses’ philosophies, influenced by the Gestalt
continuum of experiencing.
Mackay (2002) conducted a study of Gestalt two-chair work to resolve
interpersonal conflict. A structured Q-sort was constructed using the fac-
tors of conflict resolution and the Gestalt concept of contact in a 2 × 2
factorial design. Each factor was divided into two levels: conflict resolu-
tion resolved versus unresolved and contact versus interruption of contact.
The factors of conflict resolution and contact were expected to interact
before and after successful and unsuccessful therapy for decision making.
Eight participants who were ambivalent about staying married performed
the Q-sort before and after six sessions of Gestalt therapy in which the
two-chair technique was used as the primary intervention to facilitate their
pre–decision making regarding their marriages. Moderate support was found
for the three stages of the model: opposition, merging, and integration.
When therapy was successful, the factors of conflict resolution and con-
tact interacted as predicted. When therapy was unsuccessful, the factors
did not interact as predicted. They did not interact for individuals who
were experiencing a great deal of interruption of contact, indicating that the
model has a possible prestage.
Knez, Gudelj, and Sveško-Visentin (2013) discussed the use of Gestalt
psychotherapy with a 30-year-old woman with borderline personality disorder.
This is relevant because Gestalt writers have provided a theoretical founda-
tion for working with narcissistic and borderline clients (E. Greenberg, 2005;
Salonia & Müller, 2013; Spagnuolo Lobb & Stevens, 2013). Although case
reports are considered low-level evidence, they are acceptable as contribut-
ing to a form of evidence-based practice. The client had been experienc-
ing sensations of walking between life and death, feeling empty, and being

unwell. She could not make sense of her life, and she was sad and dissatisfied
with it. Unable to establish an intimate relationship for a period of 7 years,
she reported a history of dysfunctional family life characterized by consis-
tent physical and psychological abuse. Gestalt therapy was conducted in the
course of 75 sessions, carried out over 3.5 years (because at first compliance
was an issue). Emphasis was on building the client–therapist relationship,
developing the client’s groundedness in her own values, instituting personal
boundaries, developing adequate verbal expression, and ensuring compliance
with therapy.
Initially, the attempted to control therapy, to make it conform to her sense
of how it “should” be, either retreating or attacking in the process (Knez et al.,
2013). Attention was given to the awareness of her feelings, leading to choices
in appropriate behaviors toward others and retroflecting, or pulling back, in her
impulsive tendencies to evaluate the potential consequences of her actions.
She routinely externalized blame for failures in her life; however, as therapy
progressed, she was able to tolerate personal responsibility. During the last year,
she maintained continuity of therapy, mostly on a weekly basis, graduated from
the university, entered a graduate program, moved out of her parents’ home,
bought her own apartment, established an intimate relationship that resulted
in marriage, kept her permanent job, and started her own business. Change
achieved in the process revealed both a reduction in symptoms and a funda-
mental impact on aspects of personality functioning, as evidenced by success
in developing and maintaining an intimate relationship and friendships and
having greater capacity to function in educational settings, occupationally, and
in general social contexts.
In a dissertation conducted through the University of South Africa, Van
Huyssteen (2010) built on Gestalt foundational theories concerning execu-
tive functions as self-regulatory processes in Gestalt therapy (Brownell, 2009)
and the Gestalt concepts of field and self-configuration–formation as seen in
adolescent sex offenders (Brownell, 2005). Van Huyssteen conducted a quali-
tative study of the experience of juvenile sex offenders in South Africa using
an unstructured interview that started with the words “Tell me about you.” By
this method, the researcher explored the perspective and experience of the
juvenile sex offenders. To supplement the exploration, the researcher con-
ducted additional semistructured interviews with primary caretakers of juve-
nile sex offenders as well as the social workers or therapists who worked in the
field with these children. Analysis of the interviews followed. Van Huyssteen
found poor awareness of developmental field forces in the ground of offenders
(i.e., poor attachment), poor awareness of self and other (not in touch with
one’s own experience and unable to take the perspective of others), and poor
self-regulation. These were in accord with points in the theoretical foundation
described in the literature review.
232 philip brownell

Gestalt Hybrid Research
As has been observed in other contexts, emotion-focused therapy, for-

merly known as process–experiential therapy, and schema therapy integrate
Gestalt features and techniques with other constructs. These hybrids prolifer-
ate. Emotion-focused therapy, in particular, is a blend of Gestalt, experiential,
and person-centered therapy. Including it here as a true hybrid, I refer the
reader to research data on this approach found elsewhere in this volume (see
Chapter 10).
Schema therapy is a blend of cognitive therapy, Gestalt therapy, and
dialectical behavior therapy (DBT; Kellogg, 2004; Young, 2005) used to treat
personality disorders. Malogiannis et al. (2014) tested the effectiveness of
schema therapy for patients with chronic depression. Twelve patients with
that diagnosis participated in a single case series of A–B–C design, with a
6-month follow-up. Clients were assessed with the Hamilton Rating Scale
for Depression three times during baseline, at the end of phase B, and then
every 12 weeks until the end of treatment and at 6-month follow-up. At the
end of treatment, seven patients had a satisfactory response, and the mean
score on the Hamilton Rating Scale for Depression dropped from 21.07 dur-
ing baseline to 9.40 at posttreatment and 10.75 at follow-up.
Gestalt therapy, defined as a field-theoretical approach to the study of the
Gestalt formation process, complements the schema-based understanding and
practice in cognitive therapy, making the blend a cohesive hybrid. Schemas are
the residuals of experience; thus, field factors have effects on people’s lives. In a
7-year single case study using schema therapy for the treatment of psychopathy,
Chakhssi, Kersten, de Ruiter, and Bernstein (2014) found significant effect sizes
in the change along several parameters: disconnection–rejection (ES = 1.62),
impaired autonomy–performance (ES = 0.98), impaired limits (ES = 2.15),
other-directedness (ES = 0.53), and overvigilance–inhibition (ES = 2.43). After
the 4-year treatment and 3-year follow-up, the subject displayed more empathy,
guilt, and insight and better communication, no longer showing prominent fea-
tures of psychopathy.
Butollo, König, Karl, Henkel, and Rosner (2014) conducted an uncon-
trolled pilot study with 25 subjects with posttraumatic stress disorder (PTSD)
who were treated with dialogical exposure therapy (DET), combining ele-
ments of CBT and interpersonal therapy in a Gestalt therapy frame. Twenty-
one subjects completed therapy, with a significant reduction in symptoms by
self-report from pre- to posttreatment.
DET aims to restore the traumatized person’s contact-ability. The term
“contact” is used here in a Gestalt therapeutic sense, and refers to the
touching of boundaries between “me” and all that is “not me,” that is, the

process of experiencing and organizing these boundaries and—thereby—
the ongoing organization and shaping of one’s own self in its relationship
to others and the world in general. (Butollo et al., 2014, p. 515)
Their full study (Butollo, Karl, König, & Rosner, in press), a randomized,
controlled trial comparing Gestalt-based treatment for PTSD with cognitive
processing therapy (CPT) for PTSD, showed effect sizes better than those
in the pilot study. The effect sizes were high for PTSD measures and general
psychopathology and moderate to high for posttraumatic cognitions. Notably,
effect sizes for DET tended to increase over the follow-up period, whereas those
for CPT tended to stay stable or show a small decline. When Butollo et al.
(in press) calculated effect sizes using the pooled standard deviation from the
whole sample as the denominator, effect sizes were similar (at posttreatment,
2.06 for DET and 2.17 for CPT; at follow-up, 2.04 for DET and 2.06 for CPT;
Posttraumatic Diagnostic Scale [Foa, Cashman, Jaycox, & Perry, 1997] total
at posttreatment, 1.09 for DET and 1.22 for CPT; at follow-up, 1.27 for DET
and 1.22 for CPT).
The results of using chair work have been well established (Kramer &
Pascual-Leone, 2013) and continue to be studied. Elliott, Watson, Goldman,
and Greenberg (2004a, 2004b) have provided ample evidence of that fact.
The empty-chair task for unfinished business is based on the Gestalt principle
that significant unmet needs do not fully recede from awareness (Perls et al.,
1951/1972; Polster & Polster, 1973). When associated schemas are triggered in
the present, a person can reexperience these unresolved emotional reactions;
the empty chair is a means of meeting the unfinished situation through the
imagination.
In a study by L. S. Greenberg and Malcolm (2002), the presence of the
specific process of resolution in the clients’ empty-chair dialogues was also
found to be a better predictor of outcome than the working alliance. Shahar
et al. (2012) examined the efficacy of the Gestalt two-chair dialogue task at
times of stress with nine clients who were judged to be self-critical. The clients
became significantly more compassionate and reassuring toward themselves,
experiencing significant reductions in self-criticism and symptoms of depres-
sion and anxiety. The effect sizes were medium to large, with most clients
exhibiting low or nonclinical levels of symptoms at the end of therapy, with
maintenance of gains over a 6-month period (see also Lambert, 2013). Cheung
and Nguyen (2012) used Gestalt empty-chair techniques in social settings
to help nonexpressive Asian clients deal with bereavement issues, confront
parent–child relationship issues, and express feelings. These dialogues sup-
ported positive outcomes in engaging in therapeutic work on their issues,
responding to treatment within one session and showing progress within
two sessions, and expressing emotions or unresolved conflict throughout the
234 philip brownell

therapeutic process. Gestalt techniques were seen to be culturally sensitive
with Asian clients and families.
Gestalt-Consilient Research
Although there are consilient (overlapping) features between Gestalt and

many other approaches to psychotherapy, mindfulness, therapeutic presence,
acceptance and commitment therapy (ACT), behavioral experimentation,
and DBT stand out.
Qualitative research (Bennett-Levy, 2003) comparing behavioral exper-
iments (an obvious overlap with the experiment as found in Gestalt therapy)
with automatic thought records in studies of CBT have shown that signifi-
cant improvement over the latter can be achieved by experiments. Participants
attributed the difference to the impact of evidential experience. Although
new and alternative cognitions derived from automatic thought records were
believed cognitively, resulting in the sense that a subject knew them ratio-
nally, clients were still left feeling unfinished. By contrast, the new cognitions
resulting from experiments were more likely to be believed and accepted as
being true because the subjects had actually experienced them (Bennett-Levy
et al., 2004).
Mindfulness is literally the process of staying present to one’s awareness;
thus, it is rooted in the current moment. It has been defined as a moment-to-
moment awareness of one’s experience without judgment (Davis & Hayes,
2011). This is the essential connection to Gestalt therapy with its quint-
essential concern for here-and-now awareness and bracketing through a mod-
ified phenomenological process. In addition, Geller and Greenberg (2012)
made a solid case for the relevance of mindfulness in Gestalt’s processes of
dialogue, because the presence of both therapist and client requires a mindful
awareness of their meeting in the current moment.
Arch et al. (2013) compared a mindfulness-based intervention with
CBT for the group treatment of anxiety disorders. After randomized assign-
ment to adapted mindfulness-based stress reduction (MBSR) or CBT, 105 vet-
erans with one or more Diagnostic and Statistical Manual of Mental Disorders
(4th ed.; American Psychiatric Association, 1994) anxiety disorders began
group treatment. Both groups showed large and equivalent improvements on
principal disorder severity through a 3-month follow-up (ps < .001, d = -4.08
for adapted MBSR; d = -3.52 for CBT; Arch et al., 2013).
CBT outperformed adapted MBSR on anxious arousal outcomes at
follow-up (p < .01, d = 0.49), whereas adapted MBSR reduced worry at
a greater rate than CBT (p < .05, d = 0.64) and resulted in greater reduc-
tion of comorbid emotional disorders (p < .05, d = 0.49). Bergen-Cico and
Cheon (2014) conducted a longitudinal study using a mindfulness meditation

treatment (n = 108) and comparative control (n = 94) designed to exam-
ine relational changes in mindfulness, self-compassion, and trait anxiety
(prevalent in many psychological disorders), with data collected in three
waves: (a) baseline, (b) mid-program, and (c) postprogram (Arch et al.,
2013). The cross-lagged analysis indicated that mindfulness was the key
mediating variable preceding substantive changes in self-compassion and
trait anxiety.
Rimes and Wingrove (2013) conducted a pilot study of a mindfulness-
based cognitive therapy (MBCT) intervention adapted for people with chronic
fatigue syndrome who were still experiencing excessive fatigue after CBT.
The study investigated the acceptability of this new intervention and the fea-
sibility of conducting a larger scale randomized trial in the future. Preliminary
efficacy analyses were also undertaken. Participants were randomly allocated
to MBCT or a waiting list. Sixteen MBCT participants and 19 waiting-list
participants completed the study, with the intervention being delivered in
two separate groups. Analysis of covariance controlling for pretreatment
scores indicated that, at posttreatment, MBCT participants reported lower
levels of fatigue than the waiting-list group. Similarly, significant group dif-
ferences were found in fatigue at a 2-month follow-up, and when the MBCT
group was followed up 6 months posttreatment, these improvements were
maintained. The MBCT group also had superior outcomes on measures of
impairment, depressed mood, catastrophic thinking about fatigue, all-or-
nothing behavioral responses, unhelpful beliefs about emotions, mindfulness,
and self-compassion. In conclusion, MBCT proved effective for people still
experiencing excessive fatigue after CBT for chronic fatigue syndrome. All
of these studies suggest that the mindful aspects inherent to Gestalt therapy
would be as active as in the mindful aspects of cognitive therapy.
ACT is a form of behavior therapy that encourages people to experi-
ence their thoughts, emotions, and physiological sensations without evalu-
ation, as well as to act in accord with whatever values emerge for them in
the process (Thorpe & Sigmon, 2009). This is consilient with the paradoxi-
cal theory of change in Gestalt therapy and the general ethos for paying
attention, building awareness, and being mindful. Often one finds both
mindfulness and acceptance, for instance, linked even outside the Gestalt
therapy literature.
Berman, Boutelle, and Crow (2009) evaluated the effectiveness of ACT
for treatment of anorexia nervosa, using a case series methodology among
participants with a history of prior treatment for anorexia nervosa. Three
participants enrolled; all completed the study. All participants had a his-
tory of intensive eating disorder treatment before enrollment (1–20 years).
Participants were seen for 17 to 19 twice-weekly sessions of manualized
ACT. Symptoms were assessed at baseline, at posttreatment, and at a 1-year
236 philip brownell

follow-up. All participants experienced clinically significant improvement
on at least some measures; no participants worsened or lost weight even
at the 1-year follow-up. Simulation modeling analysis revealed for some
participants an increase in weight gain and a decrease in eating disorder
symptoms during the treatment phase compared with a baseline assess-
ment phase. These data, although preliminary, suggest that ACT could be a
promising treatment for subthreshold or clinical cases of anorexia nervosa,
even with chronic participants or those with medical complications.
The DBT processes of awareness, mindfulness, sensory body experience,
emotion regulation, acceptance, and the client–therapist relationship overlap
with Gestalt therapy (Williams, 2010). The dialectic itself is a meta-stance
highlighting the difference between the therapist and the client, with differ-
ence being one indicator of contact between self and other in Gestalt therapy
(Fruzzetti & Skuch, 2012). Radical genuineness in DBT validates the client,
because the therapist treats the client as an equal person (Fruzzetti & Skuch,
2012), as with the dialogical element in Gestalt therapy. Mindfulness and
emotion regulation are two primary skill sets in DBT, with the therapist work-
ing to build awareness of how the client routinely goes from a state of emo-
tional regulation to dysregulation (Fruzzetti & Skuch, 2012); this is one of the
central tenets of Gestalt therapy, in terms of an awareness of “what and how,
here and now,” achieved through a descriptive phenomenological method.
Feigenbaum et al. (2012), in a study using CORE, found DBT likely to be an
effective treatment delivered by community outpatient services for individuals
with a Cluster B personality disorder.
In another study, Pasieczny and Connor (2011) examined the clinical and
cost effectiveness of providing DBT over treatment as usual in an Australian
public mental health service. Forty-three adult patients with borderline per-
sonality disorder were provided outpatient DBT for 6 months, with outcomes
compared with those obtained from patients in a waiting-list group receiving
treatment as usual. After 6 months, the DBT group showed significantly greater
reductions in suicidal and nonsuicidal self-injury, emergency department visits,
psychiatric admissions, and days in residential treatment. Self-report measures
were administered to a reduced sample of patients. Within this group, DBT
patients demonstrated significantly improved depression, anxiety, and gen-
eral symptom severity scores compared with treatment as usual at 6 months.
Average treatment costs were significantly lower for patients in DBT than for
those receiving treatment as usual.
Beyond this, Geller and Greenberg (2012) made a strong case for
therapeutic presence as a Gestalt therapy-related factor in the therapeu-
tic relationship. They conducted qualitative research (Geller & Greenberg,
2002) surveying established therapists (each with more than 10 years of expe-
rience) from experiential, interpersonal, cognitive, and Eriksonian clinical

perspectives, finding the following elements true of therapeutic presence for
these clinicians:
77 putting aside self-concerns;
77 bracketing theories, preconceptions, or treatment plans;
77 adopting an attitude of openness and non-judgment;
77 being attentive and receptive to client verbal and nonverbal
discourse;
77 extending self for contact;
77 offering intuitive responses;
77 being absorbed, aware, and alert; and
77 being with and for the client, while remaining grounded in one’s
own experience.
Geller and Greenberg (2012) went on to describe presence as “bringing
one’s whole self to the engagement with the client and being fully in the
moment with and for the client, with little self-centered purpose or goal in
mind” (p. 17). With direct regard to Gestalt therapy, they said,
I–Thou is the natural connection that occurs when a person becomes
fully present to another . . . healing emerges from the meeting that occurs
between the two people as they become fully present to each other. The
purpose of presence, from this perspective, is the power it has in allow-
ing one to meet and hence understand the other, for the purpose of
healing. . . . Inclusion is another part of the I–Thou encounter and
is closely linked to presence because it involves being in direct and
immediate contact with another person without losing contact with
one’s self. (p. 22)
Geller and Greenberg (2012) tested the psychometrics of their construct
of presence by creating and validating the Therapeutic Presence Inventory
(TPI), including several versions and subscales related to it such as the TPI–T, a
measure of the therapist’s experience of presence in the process, and the TPI–C,
a measure of the client’s experience of therapist presence in the process.
In randomized controlled studies for therapists using process–experiential
therapy, CBT, and client-centered therapy, the items on the TPI–T fell
under one factor called Therapeutic Presence (with an eigenvalue of 10.50,
accounting for slightly more than 50% of the variance). On the TPI–C,
items fell under the same single factor with an eigenvalue of 2.03, account-
ing for 67.59% of the variance. After supporting the construct validity of
therapeutic presence, Geller and Greenberg (2012) went on to establish
the reliability of the scales and the predictive validity of the construct by
comparing them with outcomes using established instruments such as the
Working Alliance Inventory (Horvath & Greenberg, 1989) and the Client
Task Specific Measure (Watson & Greenberg, 1996).
238 philip brownell

Developing Research Tradition
Practitioners in the field of Gestalt therapy have embarked on an orga-

nized and ambitious effort to establish a research tradition for Gestalt therapy.
No longer satisfied with relying on the occasional research-specific proj-
ect, and realizing that Gestalt hybrid research does not address the fea-
tures of Gestalt therapy proper as a whole approach with its own integrity,
Gestalt practitioner-researchers have created a biennial research conference,
established research funds, and embarked on several research projects. Both
the European Association for Gestalt Therapy and the Association for the
Advancement of Gestalt Therapy have created research committees and com-
mitted to the support of the growing research tradition.
Individual initiatives are also continuing. In Hong Kong, for instance,
Man Leung is beginning a 2-year study to enhance children’s awareness of their
emotions and to promote their ability to express them. In a concomitant parent
group, she hopes to enhance parents’ awareness of their anxieties about their
children’s education, adding components of mindfulness and compassion. In
Chile, Pablo Herrera Salinas heads up an international research project for
outcomes of Gestalt therapy using a single-case, timed-series design. The study
uses Gestalt practitioner-researchers in practice-based research networks that
span several geographic regions and people groups. In Eastern Europe, practice-
based research networks are developing CORE studies of Gestalt therapy out-
comes and qualitative research using grounded theory.
Bermuda is beautifully deceptive. The warm aqua waters are a playground

for tourists, and there are rich people who live in huge, air-conditioned homes
next to private docks with expensive boats. Most of the population, however,
struggles because of the extremely high cost of living. Generations of families
live together in homes that have been expanded to accommodate the children
as they grow into young adulthood. Most young adults live with their parents,
and people often work two or three jobs at a time. It is a largely matriarchal
society in which women take responsibility and are the glue holding families
together.
Cecile,6 a Black Bermudian grandmother, 58 years old and heavyset,
entered the office, sat on the couch, and immediately started crying. Her tears
formed in silence, because she had not yet spoken a word, but they spilled out
and down her cheeks.
6
Specific identifying information on this client has been changed to protect her identity.

They caught me by surprise. I took a breath and purposefully relaxed
into my chair. I kept my eyes on her. I could see her sniffling and taking short,
choppy breaths. She pulled a tissue out of her purse and dabbed at her face.
She was not looking at me consistently; she was looking past me, over my
right shoulder, toward the blank wall.
I said, “Tears?”
She said, “My grandson.” Her eyes darted to me and back to the wall.
“Can you tell me more?” I asked.
“He was the one shot at the night club,” she replied.
“Oh,” I said. “I’m so sorry for your loss.”
I did not fill in the space more than that, but I kept watching her, follow-
ing her eyes with mine, and I shifted in my chair more toward her. I felt the
intensity of her emotion, and I could relate immediately to the extratherapeutic
situation (the field conditions) affecting us and in which we met.
In Bermuda, young men are killing each other in a tenacious gang war.
They have climbed on board a bus to murder a helplessly disabled victim, shot
up restaurants and church picnics where children were playing, and driven into
private yards on their motorbikes to assassinate people sitting on their front
porches. I have conducted critical incident stress management interventions
for hospital units and other organizations at which this situation has touched
someone. I have attended the funerals of former clients. When Cecile said what
she did, I joined her sorrow, because the gang war is a national tragedy.
Cecile engaged my eyes with hers. She said with a note of pride, “I raised
him. He was my boy,” and her sobbing increased. Her tissue wore out, so I got
up, retrieved the box of tissues from the corner table, and brought it to her.
“You raised him,” I said.
Another extratherapeutic field dynamic is that in many families the
grandparents, and often it is the grandmother, end up raising the children
(spending the most time with the children and nurturing them) because the
parents are both working long hours to make enough money for the family
to survive.
“How can I help you?” I asked. “What made you come in to see me
today?”
She said, “I just need to sit with someone. I don’t let other people see
how I feel, and I know family members have been to see you.”
“Ah,” I said. “You want me to share your grief?”
“Uh-huh,” she replied.
I said, “I am the oldest of five; I am a former pastor, and I’ve met with
grieving people and conducted funerals. I thought I knew what grief was. Then
my youngest brother was killed in a road accident, and when his wife called
to tell me, it cut through me [I made a slicing motion with my hand across my
heart] like a knife.”
240 philip brownell

Her head turned more toward me. Her eyes met mine and lingered there.
Her sobbing became more relaxed and her tears subsided. We felt the contact.
I said, “You’re breathing easier.”
She smiled.
“It’s a terrible thing that’s happening in Bermuda with all these young
men killing and being killed.”
She nodded. “It ain’t goin’ away. The pain ain’t never goin’ away.”
“Never going away?” I asked.
“Feels like it,” she replied.
Process Comments
In this excerpt of clinical process, the presence of the therapist was

immediately evident through both his verbal and nonverbal discourse. He
was there for and attentive to the client. He allowed himself to be touched by
the client and self-disclosed in various ways how the client affected him. At
the same time, he practiced a here-and-now awareness that is characteristic
of both Gestalt therapy and mindfulness, and his approach was relational and
largely dialogical.
Geller and Greenberg’s (2002, 2012) work on therapeutic presence pro-
vides a Gestalt-related research perspective on the therapeutic relationship that
is at the same time relevant to Gestalt’s adapted phenomenological method. In
presence, for instance, whereas the therapist might self-disclose in the service
of dialogue, he or she would bracket theories about the client or the process
between them to remain available to the moment-by-moment process, sim-
ply describing what is available in mindful attention to what is taking place
between the therapist and the client. Thus, it is through presence and mind-
fulness that the Gestalt therapist pays attention to the unfolding subjective
experience of the client and puts together the facets of a dialogical relationship
between the client and the therapist.
Following the therapist’s self-disclosure, the client was called into closer
contact with him, and her embodied experience became more relaxed. The
therapist switched to an adapted phenomenological method and described
what he observed. He simply said, “You’re breathing easier.”
At one point, the therapist reached for the client’s figure of interest by
asking what the client wanted to accomplish by coming in for the appoint-
ment. The client was able to say that she simply wanted someone to talk with
about her grief, someone outside of her family.
At various stages in the pericope, recognition of field factors affecting the
client, the therapist, and the meeting between them was mentioned. Simply
to recognize some of these influences is often all that is necessary in touching
the schemas that are involved. For instance, the therapist “touched” a schema

around grandparents raising their grandchildren; it is an expectation in many
families and a badge of honor by which grandparents in many cases confirm that
they are responsible and loving. To lose a grandchild to murder, then, becomes
a social insult and a very painful loss. Many times, the values and social expec-
tations that clients hold can be accessed through dialogue, through observing
the client’s expression in his or her nonverbal discourse, or through the experi-
mentation in chair work, pitting one end of a polarity against another (i.e.,
good grandparent vs. bad grandparent). That did not happen in this case, but
speaking more generally about the application of research in Gestalt therapy,
introjects emerging from the residue of experience in the client’s field can often
be affected by empty-chair and two-chair work.
Applications From Research More Generally Considered
Butollo et al. (2014) and Man Leung et al. (2013) referred to the con-
struct of contact (and the process of contacting) as being important in their
research. Man Leung et al. attributed the contacting through dialogue, experi-
ment, and the aware presence of those concerned to the increase in agency and
hope in their study subjects. In turn, they related those increases to Gestalt’s
construct of self-regulation. Butollo et al. claimed that the research conducted
that showed Gestalt therapy was effective in the treatment of PTSD implied
the relevance of contact and contacting as skills that facilitate the organi-
zation of experience. Thus, contacting is a skill that Gestalt therapists can
manifest through their work in following the subjective experience of their
clients, meeting their clients through presence in the dialogical relationship,
and supporting clients for behavioral experimentation.
The research on ACT supports the Gestalt therapy construct of the par-
adoxical theory of change—acceptance of what is and the actualization of
the person in the current moment. This construct allows the Gestalt thera-
pist to work in a descriptive manner, using the phenomenological method
without having to make sense of the client’s presentation; the therapist
simply accepts the process as it unfolds, trusting that, paradoxically, the
increased awareness of what is in the current moment will develop into
something more. It is an existential and pragmatic trust that the field will,
indeed, supply what is needed.
The CORE study conducted in England (Stevens et al., 2011) provided
evidence that, when Gestalt therapists work naturally in accord with their
training, they can be every bit as effective as therapists from other clinical
perspectives, including CBT, for clients with anxiety, depression, and rela-
tionship and self-esteem issues, among other disorders. This is encouraging.
It should settle the issue and free up Gestalt therapists simply to work in
accordance with what they have learned.
242 philip brownell

Contemporary Gestalt therapy has come of age as an integrative approach

closely associated with humanistic psychotherapy. Although Gestalt-specific
research has been sparse, researchers have generated enough of such research,
in all categories, to inform an evidence-based practice of Gestalt therapy. With
the growing movement to establish a research tradition for Gestalt therapy,
it is likely that the research literature will look quite different with regard to
Gestalt therapy within the next 5 years, with many and diverse research articles
becoming available in peer-reviewed journals.
Gestalt thinkers and practitioners have developed its original integration
into a sophisticated approach that is more than multimodal. It is undergirded
by a well-thought-out philosophical foundation that rests on continental phi-
losophy and science. It is phenomenological. It is relational and dialogical.
It is field theoretical and strategic, and it is existentially experimental. It is
unified in the practice of contacting, and this contacting is what pulls the
various tenets of Gestalt therapy into a theoretically integrated approach. A
growing research tradition is adding evidence to Gestalt’s philosophical foun-
dation, and that research has already demonstrated that Gestalt therapy is at
least as effective as other approaches to psychotherapy. Contemporary Gestalt
therapy is not the same thing many people observed in Fritz Perls’s work with
“Gloria” (Shostrom, 1963). It is not an anachronism, a relic of the 1960s. It
is a sophisticated approach that provides a solid platform for assimilating from
other clinical systems, and it is consilient with mindfulness, behavioral experi-
ments, embodied cognition, relational systems psychoanalysis, hermeneutic–
phenomenological psychotherapy, and ACT.
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8
FOCUSING-ORIENTED–EXPERIENTIAL
PSYCHOTHERAPY: FROM RESEARCH
TO PRACTICE
KEVIN C. KRYCKA AND AKIRA IKEMI
With more than 50 years of studies demonstrating the usefulness of

focusing-oriented–experiential therapy (FOT), new research findings have
provided further evidence of its efficacy in the treatment of various psycho-
logical disorders and issues. Traditional outcome research studies are being
augmented by other microprocess-oriented studies, which look closely at the
small change events clients and therapists report when reflecting on therapy.
Microprocess research on FOT represents a growing body of research that
illuminates these small steps of therapeutic change found in FOT sessions
and provides practitioners with further evidence of how and why FOT works.
This chapter includes a summary of the research on FOT since the last
review conducted by Hendricks (2002), who looked at 89 empirical experi-
mental research studies on focusing and focusing-oriented therapy, mainly those
using the Experiencing Scale (Klein, Mathieu, Gendlin, & Kiesler, 1969; Klein,
We thank Toshihiro Kawasaki for his efforts in identifying and organizing studies conducted in Japan.
http://dx.doi.org/10.1037/14775-009
S. Rubin (Editors)
251
Mathieu-Coughlan, & Kiesler, 1986). This summary positively correlates expe-
riencing level and participant-reported positive therapy outcome. We present a
discussion of the philosophical foundation for FOT. We also include transcripts
from client sessions at key points to help illuminate the principles discussed. We
conclude with suggestions on how process-oriented research modalities might
shape the trajectory of future research on FOT.
A DISTINCT APPROACH TO THE CLIENT CHANGE PROCESS
Important to our work as psychotherapists is assisting clients in finding

a lasting way of living better. This will undoubtedly involve change, most
often change that takes place over the course of several therapy sessions and
in many small steps. FOT has a distinct approach to helping clients find and
follow the leading edge of their own change process. Therapeutic change is
accomplished through first attending to one’s bodily sense of the issue, paus-
ing with it, and then following the steps of change that emerge.
As the following segment of a therapy session demonstrates, the client
touches on a felt sense of something tightening up. The therapist’s
responses empathically guide the client toward acknowledging the appear-
ance of this sense in the present moment. Note the physically felt relief the
client expresses after the therapist reflects the client’s own gesturing for a
second time.
Client: I was thinking about what to talk about before getting
here . . . in the car. I got here a bit early, and so I had some
time to think.
Therapist: Uh-huh. And something came to mind while you were get-
ting ready to come up?
Client: Well, yes, but I’m kind of not sure about it.
Therapist: Okay, so some hesitation . . . or “not sure” about it. Let me
check first: Do you want to take a minute now to check with
yourself to make sure this is the right topic—to see if it’s okay
on the inside to talk about this now?
Client: Yeah, let’s do that.
Therapist: Okay, so take a moment to settle back and get comfort-
able . . . feeling yourself sitting in the chair . . . feeling your
body resting against the seat and your arms . . . feeling how
they feel. [After a pause, noticing the client’s shoulders have
dropped a little and he has shifted in his chair several times] So, if
you can, find just the right way to sit in the chair so you can
be okay.
252 krycka and ikemi

Client: I don’t really feel all that comfortable, but I don’t think it’s
about the chair.
Therapist: So, something is like an uncomfortable feeling . . . not about
the chair?
Client: Right.
Therapist: Let’s make sure to go carefully here. You are having an
uncomfortable feeling now, just noticing . . . this isn’t about
the chair.
Client: Right, right . . . it’s more . . . than . . . that. . . . [pausing, then
trailing off]
Therapist: More than uncomfortable?
Client: Right, more like . . . [takes a deep breath]. . . more like a tight
feeling right here. [pointing to the middle of his chest]
Therapist: Tight feeling . . . right here. [mirror motion]
Client: Ughhhh, it’s not painful like pain or something, but tighten-
ing up. . . .
Therapist: The feeling is like tightening up in your middle chest area?
Client: No, IT IS tightening up.
Therapist: Ah, okay, this something right here [gesturing to the middle
of the chest] is tightening up right now as we’re talking about
it, right?
Client: Yeah, right. It’s okay though, it’s a bit better now.
Therapist: Okay, it’s eased a bit now too.
This particular client had something important to talk about, which
was at first unclear to him. The therapist, probably rightly, guessed that they
should go slowly as they discovered together what the nature of the discomfort
was. Inquiring more about the tightening would have been disruptive to the
process of discovery at this stage. More than likely, doing so would have
obliged the client to engage in cognitive reasoning at the diminishment of
directly experiencing the tightening. Going slowly, empathically guiding
the client to pay attention to subtle bodily cues, pausing, helping the client
find the right word or expression for what he or she is experiencing in the
moment, being corrected by the client, following the shifts in perception as
they move forward in small change steps—these are the basic elements that
characterize the FOT approach. This entire sequence, summed up as attend-
ing, pausing, and following, demonstrates how the FOT practitioner assists
the client’s change process.
focusing-oriented–experiential psychotherapy 253

BACKGROUND OF FOCUSING-ORIENTED–
EXPERIENTIAL THERAPY
FOT is a seamless extension of Gendlin’s philosophy, which asserts that

all life is an interaction with its environment. Experiencing, people’s touch-
stone in life, is an interaction and exists before their conscious knowledge of
it. According to Gendlin (1961), people can understand experiencing as the
bodily felt sense they have of life, as it is in the present moment. Gendlin’s
works offer a philosophically sound basis for practice and research that sup-
port the basic values of the humanistic tradition. We discuss these assertions
in the ensuing sections.
Many already know of Gendlin through the process called focusing
(Gendlin, 1978/2007). Focusing is the process of sensing what is bodily felt but
not yet a specific or identifiable feeling or thought. Gendlin first introduced
focusing to the psychological community in the 1960s as a distinct therapeutic
process that assists client change. This was roughly the same period in which he
was assisting Rogers with outcomes studies that sought to verify certain facets
of Rogers’s client-centered psychotherapy.
Early on, Gendlin (1973) used the term experiential psychotherapy to
refer to his modification of person-centered theory and practice, stating,
“Experiential psychotherapy works with immediate concreteness” (p. 317).
This somewhat curious statement points to the crux of what distinguishes FOT
from other experiential methods—that is, the explicit use of one’s directly
felt bodily experiencing. It is important to keep in mind that experiencing is
“a direct feel of the complexity of situations and difficulties” (Gendlin, 1973,
p. 317). Put another way, people’s bodily sense of the present moment is their
sense of the whole situation, not of any particular thought or feeling they
may have about it. In FOT, accessing experiencing—attending to it, pausing
with it, and following it—is data and is at the very heart of clinical work and
a client’s change process. To assist clients in their growth process, FOT prac-
titioners empathically guide their clients to explore their experiences in the
present moment without self-judgment and without suggesting any particular
psychological or behavioral outcome.
Today, the term focusing-oriented therapy (Gendlin, 1996) is used instead
of experiential psychotherapy to differentiate those using Gendlin’s theory from
those using one of the many other approaches in the extended family of
experiential psychotherapies (Greenberg, Elliott, Lietaer, & Watson, 2013).
An Overview of Gendlin’s Philosophy
Gendlin is a philosopher and psychologist whose central assertions

about psychotherapy and psychological research come from the traditions of

continental phenomenology and American pragmatism. Heidegger, Merleau-
Ponty, Dewey, Dilthey, and McKeon heavily influenced his work. From this
intellectual convergence came two primary insights: There is a basic unity to
human experience that people can sense, and experiencing is the threshold
of existence. The latter is an elaboration of the existentialist dictum “exis-
tence precedes definitions” (Gendlin, 1973, p. 322). In the practice of FOT,
experiencing is a therapeutically critical concept and a lived reality to which
FOT practitioners return again and again in sessions and in reflection on
their work.
“The sense of, and access, to existence is the life of the body as felt from
the inside, ‘your sense of being your living body just now’” (Gendlin, 1973,
p. 322). Experiencing, a richly nuanced philosophical and psychological term,
is first of all an interactional process that involves one’s self and the environ-
ment (i.e., physical context, personal history, biology, and relationships). It
is presymbolic by nature, in other words before the formation of thoughts,
emotions, or words. This formulation leads to the position that human expe-
riencing is vastly more complex and intricate than any words can describe.
Experiencing is thus a vast inner territory that can be intentionally moved
into using processes such as focusing and empathically guiding the client
toward the felt sense. FOT is based on a philosophical model in which expe-
riencing is the basis for any higher level function of human consciousness one
may identify, such as language, cognition, concepts, memory, or emotions.
Gendlin and colleagues built a practice of psychotherapy on this distinc-
tive understanding of experiencing. The philosophy and practice emphasize
that experience and, therefore, client change are recognized bodily. Especially
important for the practice of FOT is the appreciation that creating the best
environment for change involves assisting clients in accessing what is bodily
sensed by both the client and the therapist.
Interaction First: Body, Environment, and Symbolization
Interaction suggests that a human being is interaction, an extension of

his or her body and the environment. Everyday experiences, as well as those
explored in depth in therapy, and the efforts made to understand or com-
municate them are symbolizations of a much more complex interactional
base. Feelings, like thoughts, are the symbolized contents of experience that
partially reveal its salient aspects.
Another important principle is that one’s bodily felt sense gives one
access to experiencing the basic unity of body and environment. People’s
bodily felt sense is a partial symbolization of experience, one not yet fully
articulated in words or concepts people would recognize in everyday conver-
sation. Because the felt sense is only partly symbolized, it is often unnoticed

in therapy or dismissed as something inconsequential. A felt sense might be
a funny or odd feeling one has about a concern that emerges during a period
when the client struggles for words. The felt sense, as partly symbolized con-
tent, may also be present when clients encounter a wordlessness or sense of
being stuck in therapy that does not appear to represent resistance or defen-
siveness. Instead, the wordless experience is rich and meaningful.
If experiencing is the presymbolic ground from which people’s thoughts
or feelings about a situation are derived, as Gendlin (1996) suggested, then
it makes sense that they pay more attention to it. For Gendlin and the
many experiential therapists influenced by him, consciously working with
experiencing is at the heart of the changes therapists see in psychotherapy.
Therapists in the FOT tradition assist their clients to access this inter
actional, partly symbolized level of the client’s experiencing and empathi-
cally guide it.
Implicit Intricacy: Never the Same and Always Interesting
The focusing-oriented therapist assumes that clients are multifaceted

and complex sentient beings. Clients, or any person for that matter, may
never fully know the depths of existence, but they have the capacity to touch
the experience of this complexity through their bodily sense. In therapy, the
present moment is implicitly intricate, layered with meaning and subtle
experiential awareness, all of which are focused on an issue or concern. This
insight is well known today, but at the time of Gendlin’s (1961) early work it
was a provocative claim.
The FOT practitioner is skilled at noticing when clients spontaneously
engage in searching for the tentative, fluid quality of the felt sense. A client
may find and label many feelings and thoughts in therapy (e.g., self-hatred,
fear). The FOT practitioner understands that the labeled feeling, or cogni-
tion, is just the tip of the iceberg in relation to all else that accompanies its
appearance in consciousness. There is always more implicitly present in any
communication. Attending to the direct feel of the concern or situation
helps clients touch the implicit intricacy of their experience and carry it
forward.
Carrying Forward: The Felt Sense Is More Than a Feeling
Central to FOT is assisting the client in carrying his or her experience

forward. From the first two principles, it is clear that there is always more
available to people than the symbols they initially use to represent their expe-
rience. Carrying experience forward is the sign of change in therapy and is
most often noticed when the symbolizations used by clients change. When a

client makes a step forward in therapy, that step is not the end but rather an
event that will most likely lead to and shape many more.
In the example below, a client has come to therapy with the hope of unrav-
eling why he is overeating. After several sessions, the client begins to verbalize
how his overeating is somehow linked to sadness and grief. In this case, overeat-
ing is taken to be a symbolization of his grieving. Here in this small example, one
can see what the symbolization process looks like in the middle stages of therapy,
where the therapist is helping the client find the felt sense of his experience. The
felt sense is then carried forward into a different, more precise awareness at the
end of this segment:
Client: I just can’t get moving along; I just keep thinking of her and
missing her.
Therapist: You’re still missing her after all this time.
Client: Yeah, 2 years, and the only thing that makes a difference is,
like, finding ways of getting my mind off her.
Therapist: Getting your mind off her?
Client: Eating, I guess. I’ve gained 25 pounds since she died. I hate
myself for that.
[later]
Client: It’s like there’s a confusion or something about it all.
Therapist: Right, okay. So there’s confusion. And let’s just make some
room for that feeling, not just rush over it, okay?
Client: How do you mean?
Therapist: Just sit quietly for a moment, if you can, and keep it com-
pany, like you would with a friend.
Client: Oh, I see. Okay. [long pause] It’s like a not very friendly
friend! That’s for sure.
Therapist: Not very friendly, huh?
Client: Right.
Therapist: And can you get a sense of what the not-friendly feels like
from the inside?
Client: Uhh, it’s sort of like cold, feeling like being cold. [Client rubs
his arm as if trying to warm up]
Therapist: Cold. The feeling is like being cold.
Client: Yes, there’s more too, a sinking thing.
Therapist: Cold and sinking. Is that right?

Client: Yes, cold, and the feeling of sinking is familiar somehow.
Therapist: Familiar to you, right. Something about the cold sinking
feeling is familiar.
Client: I know this. It’s . . . it’s . . . I’m feeling sad. Yeah, I’m pretty
sad about all this.
At this point, the client has come from being relatively sure he hated
himself for gaining weight to not being exactly sure that this is the feeling
he means. With the help of the empathically attuned guiding therapist, his
process was carried forward, and now he is sure he is sad. “Being cold” in this
case was not quite right; it was close, but only an approximation that pointed
to something more, to sadness. Hate only partially carried the meaning of
overeating, but sadness was the better fitting word.
As this transcript shows, the felt sense is at first fuzzy, subtle, and tenta-
tive, an implicit intricacy just beyond words. FOT practitioners recognize
this fuzziness as an indication that clients are working at the edge of their
experiencing, on the border zone between the presymbolic and symbolic.
The first words clients choose to represent this fuzzy edge are their tentative
sense of what is presently known to them about an issue. These tentative
understandings change, often quite rapidly, in the course of a therapy session.
Not all clients are comfortable with the tentativeness or fuzziness of the
felt sense, especially if they are looking for something definite about which
they can take action. It may take some time for clients to trust their own
searching, to see it as a valuable part of the healing process. The felt sense can
be elusive as well when one is purposefully searching for it. However difficult
following a felt sense might be, it is important to note that most clients can
be taught how to attend to it.
In total, these three assertions about experiencing affirm why it is
important that the therapist be open to guide the process of discovery in a
curious, searching manner, centering on the concrete lived expressions of the
client. As Rogers (1975) put it, the client is “checking them [the therapist’s
responses] against the ongoing psycho-physiological flow within himself to
see if they fit. This flow is a very real thing, and people are able to use it as a
referent” (p. 4).
DEVELOPMENTS AND DEPARTURES
In the mid- to late 1950s, Gendlin and colleagues at the University of

Chicago, under the direction of Carl Rogers, conducted a series of studies
that influenced the direction of psychotherapy outcome research (Gendlin,

1962; Gendlin & Berlin, 1961). Around the same time, Rogers wrote on
what he felt were the core psychological qualities of the therapist needed for
positive therapeutic outcomes (Rogers, 1957).
By 1968, Gendlin had diverged from Rogers in a key way: Gendlin
saw that it was the manner in which the client processed experience that
made the difference between successful and unsuccessful outcomes. The
therapeutic relationship mattered, of course, but Gendlin believed that a
promising approach in research would be to investigate more specifically
what the empathically attuned therapist was following while listening to
the client.
Another departure from Rogers lay in Gendlin’s theory of psychotherapy
and personality change (Gendlin, 1964). Gendlin’s theory, in many ways a
refinement of Rogers’s (1959) original theory, went in a different direction.
Gendlin’s view was that growth occurs when clients attend to their experi-
ence (i.e., focusing) rather than as a function of assisting clients’ actualizing
tendency. Gendlin also differed from Rogers regarding whether the client
must perceive the core therapist conditions. He thought Rogers’s emphasis
on whether a client consciously perceived these conditions was misguided,
because the body is already engaging in the therapeutic process before per-
ceiving these conditions.
Last, Gendlin diverged from what Purton (2004) called the standard
view of person-centered therapy regarding whether any procedures such as
instructions that guide focusing are compatible. Complete adherence to non-
directivity in person-centered therapy appears to be at odds with the process-
guiding approach found in FOT.
Although focusing instructions in therapy may seem like an intrusion
or imposition of a technique, when therapists introduce focusing instructions
they are ideally grounded in deep empathy. When clients are stuck and need
help identifying their lived feeling of a problem, the focusing-oriented thera-
pist helps by gently guiding the process. Most often, clients do not experience
this guiding as intrusive or controlling. Not only is recognizing and then
helping clients move toward experiencing practicable for success in therapy,
it is highly prized in FOT.
Eventually, Rogers (1975) did embrace Gendlin’s experiencing concept,
although he did not engage in focusing with his own clients. It is clear that
Rogers’s reformulation of empathy came about partly because of his agree-
ment with Gendlin’s assertions, about which Rogers stated, “I believe it to
be a process, rather than a state” (p. 4). Thus, for both Gendlin and Rogers,
psychotherapy and research eventually came to focus on how therapists and
clients together encourage the further flow of experiencing when expression
closely matches its feel.

FOCUSING-ORIENTED–EXPERIENTIAL
RESEARCH THROUGH 2000
Hendricks (2002) reported on the body of research that has established

the empirical validity of FOT. Hendricks reviewed 89 studies from a variety of
clinical settings and problems. The research showed that a strong predictor of
positive outcome in therapy was the manner and extent to which the therapist
was able to help clients find and follow their present moment experiencing
in session. Twenty-seven studies showed that (a) higher experiencing levels
correlate with a more successful outcome in therapy in a variety of therapeutic
orientations and client problem types; (b) clients can be taught the ability to
focus and increase the experiencing level; and (c) therapists who themselves
focus seem to be more effective in enabling their clients to focus.
Experiencing Scale
Gendlin and colleagues developed an observer-rated scale called the

Experiencing Scale (EXP; Gendlin, 1961; Klein et al., 1969, 1986), which
measures the level of experiencing. A higher level of experiencing was pre-
dicted to correlate positively with good therapy outcomes. This central
hypothesis has held up over the course of 5 decades of research (Greenberg,
Elliott, & Lietaer, 1994; Hendricks, 2002).
In the typical research protocol using EXP, a trained rater reviews video
taped session recordings and determines the EXP level. At lower levels of
experiencing, clients speak of external events only or refuse to participate
and reference personal reactions to external events. At the middle levels
of experiencing, clients will describe personal experiences and feelings, will
readily present problems or theories about them, and will be able to syn-
thesize these readily available feelings and experiences toward resolution of
problematic or significant issues. At the highest EXP level, clients demon-
strate full and easy access to experiencing, and all its elements are confidently
integrated (Klein et al., 1969, p. 64).
In 39 studies reviewed in Hendricks (2002) on whether teaching focus-
ing would significantly increase EXP level, it was found that focusing or EXP
level increased when focusing was introduced by a trained focusing profes-
sional (e.g., by helping a client sense inside and pause to find a feeling quality
or felt sense). Hendricks noted that in 11 studies a higher EXP level could be
achieved during the training period, but this high level of experiencing was
not maintained very long after ending focusing training. These studies did
not fully address the decrease in EXP level after training. Two factors may
have contributed to that decrease: (a) The studies were of relatively short
duration and (b) it takes time to learn focusing fully.

Statistically significant correlations with successful outcome were found
when participants reached the higher EXP levels (Stages 4–7). Goldman’s
(1997) multiple-case study showed that the experiencing level increases as
the client is able to identify, accept, and stay with unclear, or fuzzy, thoughts
or feelings. His study affirmed that clients at the highest experiencing level,
Stage 7, spontaneously refer to the edges of their awareness and pause to find
clarity, with little help needed from the therapist. Furthermore, Goldman
found that good therapy outcomes required some preparation for most par-
ticipants and clients.
A series of studies reported by Sachse (1990; Sachse & Atrops, 1991)
showed that the quality of the therapists’ responses could increase, maintain,
or even flatten the clients’ depth of experiencing. For these clients, the pres-
ence of a skilled focusing professional who makes high-quality deepening
processing proposals facilitated successful therapy.
In a study not reviewed in Hendricks (2002), Kubota and Ikemi (1991)
investigated whether focusing ability, as rated by the EXP, was a personal-
ity trait that is relatively stable and not easily affected by the immediate
therapeutic relationship. To investigate this, they studied videotaped inter-
views of 35 medical students who were training in experiential listening for
four 3-hour listening sessions. Both the speaker and the listener filled out
the Short Form Relationship Inventory after the interview. This inventory
measures listeners’ congruence, unconditional positive regard, and empathy,
as perceived by the speakers and by the listeners themselves. Trained raters
using the EXP then rated the recordings. Kubota and Ikemi found no cor-
relation between the EXP and the Short Form Relationship Inventory. They
concluded that the manner of experiencing is not immediately affected by
the perceived relationship. However, they did not rule out the possibility that
the relationship may be enhanced as it develops over time.
In another study, Hiramatsu, Ikemi, and Yamaguchi (1998) devised an
EXP for sand-play therapy, a form of art therapy popular in Japan and origi-
nally developed in a Jungian context by Kalff (1996/2004) in Switzerland.
The sand-play EXP rates the verbalizations of clients talking to their thera-
pists about the sand-play art they have just created. Fifteen clients partici-
pated in sand-play therapy for 12 sessions. Five expert sand-play therapists
using a checklist for sand-play evaluation rated photographs of the sand-play
art. The evaluation found that four of the clients made considerable progress
during the 12 sessions, and four others showed little or no progress. Three
trained raters rated the EXP levels of these eight clients under a blind condi-
tion, using the sand-play EXP. Their ratings were reliable, and the ratings
were done again 2 months later to confirm test–retest reliability. Significant
differences in both mode and peak EXP levels were found between the four
high-progress clients and the four low-progress clients. This study may have

been the first to find that the manner of experiencing is related to psycho-
therapy outcome even in nonverbal forms of therapy such as sand play.
Hendricks’s (2002) review clearly showed that experiencing was the
central process in focusing, yet focusing practice had already evolved by then
to include specific use of other experiential dimensions (e.g., the body, inter-
action, spirituality). One of the most prominent and well documented of
these is CAS.
Clearing a Space
Clearing a space (CAS) was the first microprocess of FOT to be studied

in a systematic manner (Gendlin, Grindler, & McGuire, 1984). Originally
understood as an optional preparation for focusing, in the Gendlin et al. (1984)
study the CAS protocol was developed with the aim of assisting women with
cancer with finding a psychologically safe space between themselves and their
bodily felt concerns. It was thought that pinpointing such a distance would
reduce the stresses associated with being diagnosed with cancer.
The CAS protocol begins with helping individuals find a way to focus
internally in an accepting and nonjudgmental way while taking an inven-
tory of their current felt issues or concerns and gently placing each concern
aside for the moment. After one or more issues of concern are identified, the
individual is guided to clear an inner space and to spend some time there.
Several studies summarized below have confirmed that CAS helps establish
an emotionally safe place from which people are better able to identify which
concerns are of most importance and then work with them in a more produc-
tive manner.
Results showed that practicing CAS resulted in a statistically signifi-
cant reduction in depression and increased positive body attitudes by low-
ering the level of stress experienced and increasing clients’ positive body
image. Katonah (1999) also found a significant correlation between her CAS
Checklist and the EXP along with solid interrater reliability. Validity was
established through correlation with the Secord and Jourard (1953) Body
Cathexis Scale. Reliability was verified using the Spearman-Brown split-half
reliability test (Katonah, 1999).
Results from Katonah’s (1999) initial study—as well as two others, one
using CAS with AIDS patients (Krycka, 1997) and the other with weight
loss (Holstein, 1990)—showed promise for CAS use in health-related popu-
lations. In addition, the CAS protocol has been used as a therapeutic tool in
case studies that looked at borderline personality disorder (Katonah, 1984)
and suicidal ideation (McGuire, 1984). These studies showed that teaching
CAS produced constructive psychological outcomes such as an increase in a
positive sense of self and body image and a decrease in depression.

An invitation to find a clear space can be made in any therapy session.
For example, in the following therapy excerpt, Gendlin (1996) demonstrated
how his responses encouraged the client to dwell in this clear space:
C3: Feel like I’m crumbling. That shakiness inside, and . . . I feel real
shaky about coming here.
T3: It would be nice if we could first ease it. Let’s make a little space and
stand back a little from it . . . and say, “Oh yes . . . that’s right to be
there. . . . It feels like . . . it feels at least like there’s going to be a lot
of stuff crumbling, and it’s going to be very shaky-making.” . . . It
feels like that now, at least . . . do you know, like if a building were
going to crumble, you would stand back half a block.
C4: Hmm. We don’t know how much crumbling it needs, but—
(Long silence)
C5: Yes, I feel a little bit back, but—
T5: Hmm, spend a few minutes until you can have a nice feeling
about this, like there’s going to be a big change, and—. (Gendlin,
1996, p. 121)
As is evident in T3 and T5, the therapist’s responses here are not
intended to carry forward the experiencing of crumbling or the shakiness
inside that the client reports (C3). Instead, they aim to help the client stand
back (T3) and to secure a space where the client can have a nice feeling
about it (T5).
Thus, space, or the adequate control of experiential distance from over-
whelming feelings or situations, seems to constitute one of the therapeutic
agents of FOT. Practitioners of FOT began to note the therapeutic effects of
CAS by itself. Case studies such as those of Gendlin (1961, 1967; Gendlin
& Berlin, 1961) and several research studies such as those summarized above
and also below have continued to demonstrate the effectiveness of CAS as a
therapeutically valuable, supplementary process to FOT practice.
CURRENT LITERATURE REVIEW: FROM 2000 TO THE PRESENT
In this section, we include both macro- and microprocess research. The

EXP and the Focusing Manner Scale—Aoki—English version developed in
Japan (Aoki & Ikemi, 2014) are two of the most widely used of the macroprocess
research tools that link FOT process with therapy outcomes. Microprocess
research that focuses on what occurs within a session, or inferred psychologi-
cal processes related to focusing, has included the CAS protocol and case

studies. The case study method continues to be a common way for researchers
to augment quantitative data or simply to explore dimensions of therapy inac-
cessible to quantitative approaches. In general, the entirety of the research
reviewed in this section has continued to support FOT as an empirically sup-
ported practice. New to this review of FOT are promising avenues for future
research that focus more specifically on in-session client change and therapist
behavior.
Current FOT research has shown a gradual change in what is consid-
ered most relevant by FOT researchers and practitioners. The research has
shifted from more traditionally defined macroprocess, or outcomes research,
to microprocess-oriented research. This is an important development, one
that we discuss further below.
We believe that this shift is driving the kinds of research being con-
ducted. For many FOT researchers and therapists, the relevant questions for
research now revolve around whether and how clients access their ongoing
experiencing and its relationship to client change (i.e., microprocesses). Thus,
studies examining the activities of the client in session (e.g., FOT micro
processes) have become the main thrust of recent research.
A final important question is whether CAS is a new form of FOT or,
rather, as it was conceived when it was first developed, it is a helpful step that
assists clients in creating a psychologically safe place from which to work
therapeutically in FOT. Katonah (2012) characterized CAS as “an experi-
ential process [that has been studied] in its own right” (p. 138). Klagsbrun,
Lennox, and Summers (2010) went so far as to state that it “can be used alone
as a freestanding stress-reduction method” (p. 155). The evidence we present
below has shown that CAS is a mechanism for therapeutic change, but this
evidence does not completely answer the question of whether CAS is a dis-
tinct focusing-inspired form of therapy. This question remains to be explored.
Macroprocess Research: Experience Is Key to Outcome
EXP
Studies using the EXP have continued from 2000 to the present, with
researchers investigating such areas as the manner of experiencing in senile
dementia (Ichioka, 2000) and using changes in EXP levels before and after
the pause (i.e., moments of silence in focusing and therapy) to explore what
happens within that pause (Uchida, 2002). A Five-Stage EXP (Miyake,
Ikemi, & Tamura, 2008) has been developed that simplified the original rat-
ing criteria to eventually develop a paper-and-pencil therapist evaluation
form of the EXP. In addition, this scale has been used by other FOT research-
ers in similar therapeutic approaches to help validate their own theories of

psychotherapy and to explore such in-session microprocesses as awareness
of emotion. Excellent reviews by these theorists are available elsewhere,
and we therefore do not repeat them here (Elliott, Greenberg, & Lietaer,
2004; Elliott, Greenberg, Watson, Timulak, & Freire, 2013; MacLeod &
Elliott, 2012).
In a study involving 40 adult therapy clients, Toukmanian, Jadda, and
Armstrong (2010) hypothesized that a strong positive correlation would exist
between depth of experiencing (EXP) and the ability to engage in complex,
internally focused mental operations. Three mental operations were studied—
differentiating, reevaluating, and integrating. To test the hypothesis, the EXP
was correlated with several scales, including the Tennessee Self-Concept
Scale and the Perceptual Congruence Score developed by Toukmanian et al.
(2010), which measures self-schema change. Such change is
conceptualized as the process of moving away from a less complex and
rigid view of self that is incongruent with one’s felt experience of self,
to a more complex and flexible construal of self that is congruent with
one’s perceptions of self in interpersonal situations. (Toukmanian et al.,
2010, p. 43)
The treatment group showed significant early to late therapy improve-
ment in the three mental operations. The EXP Scale significantly correlated
with participants’ level of perceptual processing. This is important for thera-
pists because it indicates that as clients deepen their experiencing level, their
ability to evaluate their mental state and differentiate it from other states of
mind also increases. The ability to differentiate depression from worry, for
instance, could point to more realistic self-evaluation, reevaluation, integra-
tion, and improvement.
Focusing Manner Scale

In Japan, Aoki and Ikemi (2014) developed a new and potentially
important scale for English-speaking researchers, namely, the Focusing
Manner Scale—Aoki—English version (FMS). The FMS was originally
developed by Fukumori and Morikawa (2004) and validated in Japan for a
Japanese-speaking and -writing population. The FMS, along with its later
versions, tests the degree to which focusing attitudes are present. The FMS
subfactors related to focusing manner are (a) accepting and acting from expe-
riencing, (b) bringing awareness to experiencing, and (c) finding a comfort-
able distance from experiencing. The scale has been revised several times
in an attempt to better communicate the indicators of focusing attitude for
a Japanese audience and then again for an English audience, resulting in
the English version of the FMS. One advantage of the FMS is that it can
be extended to the population at large, whether the respondents have had

focusing experiences or not. Thus, Japanese studies with the FMS could be
carried out with a relatively large sample size.
Aoki and Ikemi (2014) reviewed 19 studies with the FMS done in
Japan, many of them correlational studies in which the FMS was found to
correlate positively with such scales as the General Health Questionnaire
(Fukumori & Morikawa, 2004), Cornell Medical Index (Nakagaki, 2007),
Tri-Axial Coping Scale (Yamazaki, 2005), Narcissistic Vulnerability Scale
(Matsuoka, 2006), Tokyo University Egogram (Nakagaki, 2006), Emotional
Intelligence Scale (Nakagaki, 2006), Sense of Trust Questionnaire (Kawasaki
& Aoki, 2008), Self-Actualization Scale (Aoki, 2008), Resilience Scale
(Aoki, 2008), Self-Affirmation Scale (Saito, 2008), Assertive Mind Scale
(Saito, 2008), General Self-Efficacy Scale (Doi & Morinaga, 2009), Kikuchi’s
Social Skill Scale (Doi & Morinaga, 2009), and Locus of Control Scale (Doi
& Morinaga, 2009). Two studies investigating correlations between the FMS
and EXP showed conflicting and, therefore, inconclusive results. An impor-
tant study on the FMS is that of Yamazaki, Uchida, and Itoh (2008), who
studied the FMS with 146 college students and used path analysis to interpret
the data. They found that focusing attitudes as measured by the FMS reduced
the tendency for depression as measured by the Japanese version of the Self-
Rating Depression Scale. The use of path analysis in this study is significant
because it shows causal relationships—that is to say, focusing attitudes had a
causal influence on the reduction of depression.
Aoki and Ikemi (2014) also showed that certified focusing professionals
scored significantly higher on all subscales of the FMS compared with non-
focusers. Thus, one can speculate that long-term focusing experience may
enhance focusing attitudes.
These studies using the FMS have shown that attitudes toward one’s
experiencing, frequently called focusing attitudes, correlated with positive
psychological qualities and reduced the tendency toward depression. More
over, long-term practice of focusing may enhance focusing attitudes, which
in turn may augment the psychological qualities mentioned above. Although
the FMS has only now been published for English speakers, it holds great
promise as another focusing-specific instrument used in research.
Microprocess Research: Documenting Client In-Session Change
CAS Protocol
A number of recent studies, including several from Japan, have exam-
ined the usefulness of the CAS protocol as a valuable addition to FOT
research. CAS studies have been applied to a wide range of subject popula-
tions, including college students, patients with cancer, people with chronic

pain, and people who have experienced childhood trauma. As discussed
below, the research has indicated that CAS functions more therapeutically
than originally conceptualized and is related to changes in self-perception
and stress reduction.
In Japan, two graduate clinical psychology students taught CAS on an
individual basis to 12 peer supporters for three sessions over a 3-month period
(Koshikawa, Isobe, & Ikemi, 2012). Peer supporters are contemporaries of
currently enrolled students who provide a variety of help to students. The
Tri-Axial Coping Scale, a measure of stress coping, and the FMS, a measure
of focusing attitudes, were administered to the 12 peer supporters before and
after this 3-month period. Results indicated that Avoid-Thinking (a sub-
scale of the Tri-Axial Coping Scale) showed statistically significant increases
over this period. This finding suggests that peer supporters were more able to
cope with issues by distancing themselves, avoiding thinking about or being
obsessed with issues.
Ide and Murayama (2008) conducted CAS with 15 elementary school
children in a child residential shelter. They measured the effects with the
Sentence Completion Test (Sano & Makita, 2008) and the Self-Direction
Scale (Asami, 1999). CAS facilitated children’s sense of self-direction and
reflective self-expression, producing positive changes in the relationships
between children and care workers.
In another study (Uemura, Yamami, Saeko, Hikari, & Ikemi, 2012),
22 Japanese university students were taught CAS as a way to reduce state
anxiety, which was measured by the State–Trait Anxiety Index (Hidano,
Fukuhara, Iwawaki, & Soga, 2000). Results showed that state anxiety
declined significantly during CAS.
These findings suggest that CAS allows one to find a safe space, a com-
fortable psychological distance from one’s problems or concerns, as indicated
by significant increases on the Avoid-Thinking subscale in the Koshikawa
et al. (2012) study. Despite the fact that avoid-thinking gives an impression
of avoidance, it is an effective coping strategy; Uemura et al. (2012) found
that state anxiety is indeed reduced through CAS. Ide and Murayama (2008)
found self-direction, reflexive self-expressions, and positive changes in rela-
tionships with the reduction of anxiety and a comfortable psychological dis-
tance from concerns. When the results of these three studies are considered
together, their seemingly paradoxical findings can be woven together into a
coherent whole.
In what was the first art therapy study to use a mixed-methods approach
incorporating focusing (Klagsbrun et al., 2005), 18 women with breast cancer
were taught CAS before a 2-day therapy retreat that included use of vari-
ous forms of the expressive arts such as painting and movement. Significant
improvements were found on such pre–post measures as Functional Assessment

of Cancer Therapy for breast cancer (FACT–B; Brady et al., 1997) and
Functional Assessment of Chronic Illness Therapy—Spiritual (Peterman,
Fitchett, Brady, Hernandez, & Cella, 2002). FACT-B is a 44-item self-report
measure assessing one’s quality of life, including physical, social, family, emo-
tional, and functional well-being. The Functional Assessment of Chronic
Illness Therapy—Spiritual measures the relative importance of spiritual
values and beliefs for the cancer patient. Klagsbrun et al. (2005) found
only modest change to higher levels of experiencing as a result of learning
CAS, but a strong correlation between learning how to clear a space and
quality of life (FACT–B). Interestingly, the participants showed significant
improvement in body image when those with an already high EXP level
were factored out.
Klagsbrun et al. (2005) suggested that the increase in experiencing
level overall was due to the composition of the subject pool, most of whom
were involved in other nonmedical treatment modalities that likely height-
ened their experiencing level before the study. The strong improvement in
body image in those who were not rated high on the EXP suggests, however,
that CAS does increase the experiencing level for those who are not already
actively involved in other self-improvement strategies.
In another study conducted by Klagsbrun et al. (2010), 17 participants
were taught CAS in six 30-minute sessions. Participants were all Caucasian
and between 43 and 65 years old. All but two had children, and nearly all
(16 of 17) had a college or graduate-level education. All participants com-
pleted a post-CAS checklist to ascertain the degree to which they were able
to set aside a difficulty and reach a “cleared space.” Two delivery methods
were used. Sessions 1 and 6 were in person; the others were conducted over
the phone. A waiting-list control group was administered four pre–post instru-
ments (FACT–B, Grindler Body Attitude Scale [Grindler, 1991], Inventory of
Positive Psychological Attitudes 32R [Kass et al., 1991], and Brief Symptom
Inventory [Grindler, 1991]) after Sessions 1 and 6 and then again after
6 weeks. Pre–post intervention results showed a statistically significant dif-
ference between treatment and control groups on the FACT–B instrument.
No significant differences were found on the other instruments (Grindler
Body Attitude Scale, Inventory of Positive Psychological Attitudes 32R,
Brief Symptom Inventory) or delivery methods. This study demonstrated that
teaching CAS can improve one’s quality of life, as measured by the four instru-
ments used. Also important for many therapists is the finding that providing
CAS in either delivery method (in person or over the telephone) increases
one’s overall sense of well-being, calmness, and enhanced emotional regula-
tion. It appears that providing CAS over the phone is as beneficial an alterna-
tive treatment as being taught CAS in person. For some, being able to receive
CAS in a cost-effective manner would be important.

The effects of focusing and CAS on the experience of chronic pain were
studied by Ferraro (2010). Focusing and CAS were taught over a 10-week
period. The study assessed levels of depression, anxiety, and pain and body
attitude. Results described participants as having a 28% decrease in depres-
sion, a 23% decrease in anxiety, a 21% decrease in experienced pain, and a
34% improvement in body attitude. Although these gains are modest, the
results are augmented by the qualitative analysis of session transcripts, which
indicate that patients did find a pain-free area in their bodies—a primary
reason to use the CAS protocol with clients with medical conditions. In this
case, the session transcripts supported this use while failing to make clear
whether the entire focusing process or the CAS alone was responsible for the
changes. As in the other studies mentioned that used the CAS protocol, this
study showed the benefit of becoming aware of one’s present-moment experi-
ence, finding a sense of optimal psychological distance from it, and then iden-
tifying a state in which one experiences a relative absence of or relief from
the condition being studied (e.g., chronic pain or anxiety). This procedure
is not unusual in the treatment of anxiety, in which it is important to find,
first, an emotionally safe place from which to work on the issues or concerns.
Leijssen (2007) discussed her use of CAS in helping clients develop
a healthy intrapsychic relationship by connecting with ongoing bodily
experiencing. The case studies presented demonstrated the importance of
finding just the right relationship with one’s experiencing through what
Leijssen called the inner guide. Being too close to a feeling state can be just as
problematic for psychological equilibrium as being too far from the feeling.
Negotiating one’s inner terrain is assisted by the use of CAS. Leijssen con-
cluded by suggesting that internalized success at finding just the right distance
from one’s problems becomes “a powerful [re]source” (p. 269) for intra- and
interpersonal change.
Katonah’s (2010) work, along with that of the growing number of research-
ers using her protocol, demonstrated that “clearing a space shifts one’s rela-
tionship to particular issues towards a greater unification of the person and
alignment with higher values and purpose” (p. 157). It now appears that
clearing a space is a therapeutic modality with demonstrated positive impact
on increased self-care, body image, recovery from trauma, and experiences of
wholeness, among other psychological states.
In addition, these studies suggest that the process of clearing a space is
not merely a pretherapy option but stands on its own as an important addi-
tion to traditional treatment for a variety of psychological conditions. As
mentioned earlier, whether CAS will be studied as a stand-alone, focusing-
inspired, psychotherapy practice remains to be seen. At the time of this
writing, this course seems probable, in which case CAS and focusing will
likely remain linked.

Case Studies
A growing body of case studies have demonstrated successful psycho-
therapy outcomes of FOT. Several published in psychological journals have
either shown a successful psychotherapy outcome with FOT or demonstrated
particular focusing-oriented ways of approaching the client’s condition. These
studies have covered a wide range of disorders, difficulties, and modalities,
including writer’s cramp (Harada, 1994), somatoform disorders (Ikemi, 1997),
chronic pain (Geiser, 2010), depression (Hikasa, 1998; Ikemi, 2010; Kurose,
2008), borderline personality disorder (Hoshika, 2007), dissociation (Coffeng,
2005; Krycka, 2010), depersonalization (Hoshika, 2012), trauma (Coffeng,
2004; Rappaport, 2010), anxiety disorder (Koizumi, 2010), panic disorder
(Ikemi, 1997; Uchida, 2011), eating disorder (Hikasa, 2011), HIV/AIDS
(Krycka, 1997), couples (Amodeo, 2007), parent interview of a child with
adjustment difficulties (Doi, 2006), family therapy (Arimura & Kameguchi,
1990), and art therapy (Rappaport, 2009). These case studies and applications
of FOT open up a wide variety of conditions to which FOT has been applied.
Some have shown specific modalities of implementing FOT or specific ways
of approaching particular conditions.
Other Developments: Special Populations and Therapist Relationships

We briefly discuss two other developments below, because an increas-
ing number of focusing-oriented therapists are involved in them. Although
these areas carry the potential for future research, there are currently few or
no rigorous outcome studies in these areas.
Children’s Focusing
The application of focusing to children has continued to grow since
Martha Stapert integrated focusing into individual child psychotherapy in
1985 in the Netherlands. Since 1998, the International Children’s Focusing
Conference has been held every other year. National organizations for chil-
dren’s focusing have formed in the Netherlands, Japan, and Romania, testi-
fying to the significance of this development. Literature regarding children’s
focusing is found on The Focusing Institute website (http://www.focusing.
org), which currently carries 78 articles on the subject. These articles embrace
such applications as child psychotherapy, methods of teaching focusing to
children, the significance of focusing for school teachers, and the use of
focusing-oriented teaching methods in the classroom.
Therapist Focusing
A substantial body of studies is developing, particularly in Japan, on
the use of focusing by therapists. This application includes using focusing

for therapy supervision (Itoh & Yamanaka, 2005; Kobayashi & Itoh, 2010;
Madison, 2004), for therapy training (Ikemi & Kawata, 2006), for therapists
who are experiencing difficulties with their clients (Kira, 2002, 2010), and
for the therapists’ own reflection about their clients (Yamazaki, 2013). These
studies have consistently reported that therapist focusing enhanced under-
standing of the client or understanding of the therapist’s way of relating to
the client. Controlled outcome studies are needed in this area.
The Manual for Therapist Focusing was developed to assist therapists to
focus on the felt sense of their clients (Hirano, 2012; Kira, 2010). It serves
as a supplement to therapy supervision or as an alternative approach to aid
therapists with difficult clients.
We conclude our review by reiterating that both macro- and micro-
process research has demonstrated that FOT is a valuable, reliable, and effec-
tive psychotherapeutic practice. Research since Hendricks’s (2002) review
has supported her findings, showing that FOT is an evidence-based practice.
Research on FOT has a number of practical implications of interest to

researchers and psychotherapists, particularly as they identify best practices
for FOT practitioners. In general, research has suggested that therapy will be
effective if the therapist focuses on the three key tasks of FOT: (a) assisting
clients in self-exploration through their bodily felt sense, (b) being a genuine
and empathic companion to that exploration, and (c) assisting clients in
identifying the next step forward in their lives. The findings also support the
assumption made by most FOT practitioners that processing the bodily felt
sense appears to help clients deepen their therapeutic work and achieve a bet-
ter therapy outcome. It seems useful to consider briefly the therapeutic tasks
associated with FOT and how client change occurs in the FOT approach.
Following is a longer transcription of a therapy session highlighting
these key elements as well as helpful empathic guiding responses. The tran-
script is from a psychotherapy session with a woman who had just learned of
a new, potentially life-threatening cancer diagnosis. She was very upset, as
one would expect, yet she was honoring and being with her present-moment
experience. Clinicians and researchers might appreciate the development of
the session over several distinct periods, marked by the intensification of her
experiential processing and a return to honoring and being with her experi-
ence. The entire focusing process of finding, attending to the felt sense, paus-
ing, and carrying it forward into one’s life is demonstrated here.
Client: I just got tired of everyone telling me that I would be fine
and everything would work out. I just wanted someone to

sit with me and state the obvious, that sometimes cancer
SUCKS!
Therapist: Ah, yes, this sucks [takes a deep breath] and you just want
someone to be upfront about that and not give platitudes.
Client: I mean, I guess people are trying to be helpful, but that isn’t
what I need now. [pausing briefly] I feel it’s so important to
ME to . . . to . . . I don’t know . . . to. . . . [becomes still and
looks down]
Therapist: Let me see right here if we can pause for a minute or so.
Something feels so important . . . to YOU.
Client: [Clutching a tissue in her fist] I’m . . . [takes a big breath] . . . I’m
swimming inside my head . . . my guts are all jumbled . . . 
I. . . .
Therapist: So, there’s some intensity here, as you say there’s swimming
inside your head and [therapist mirrors the clutching motion]
your guts are jumbled up. . . .
Client: Yeah [making a circling motion around her lower abdomen],
right here . . . it’s all jumbled.
Therapist: Right here [mirroring], right here is where you feel the jumbled-
upness. Can you just take a moment more here to see if that
has something to say more?
Client: [Takes another deep breath] I’m sure it’s . . . no, no . . . not
jumbled . . . more like certain. Yes, it’s . . . I’m certain of. . . .
[appears to be searching again for something]
Therapist: Certain of something, not jumbled, down here.
Client: Definitely certain now . . . yep . . . certain. [Hands making
more circling gestures]
Therapist: Ah, okay, that part’s for sure . . . it’s certain of something.
Ah, okay . . . certain . . . with this part too. [Repeats similar
hand gesturing]
Client: [Looks up at therapist] Certain. I like hearing that back from
you. [Therapist holds client gaze; client settles back into her chair,
appearing to be more relaxed, her hands now unclenched.]
Therapist: It’s good to hear “certain” back. [Therapist settles back as well,
unclenching own hands. A few moments of silence pass.]
In this transcription, one can see person-centered work going on, but
also guiding in the service of helping the participant find her felt sense and
stay with it. She has a clear felt sense that, in this case, is demonstrated not

so much with explicit words but with simple language accompanied by ges-
tures. Often the felt sense is still only partly articulated, but it nonetheless
has movement in it. The session resumes after the silence into a more meta-
cognitive self-appraisal, though it is still connected to the felt sense.
Client: I have truly learned the value of letting myself be exactly
where I am rather than where I sometimes want to be. So
many lessons along this journey! I cannot go around any
of it, but must move through it with as much grace as I can
muster.
Therapist: [Takes a deep breath] There seems to a big realization
here . . . something inside has shifted to a . . . can I
say . . . new perspective?
Client: Yes, something has shifted [said with emphasis and lean-
ing forward] . . . and I guess it’s big, but not so much “big”
as . . . hmm, well maybe something tectonic is going on now
inside me. . . .
Therapist: Something tectonic? Like deep underneath, it all is moving?
[Several-second pause. She is looking down in her lap.]
Client: Ah, that really hits me right here in my heart. [Points to the
middle of her chest]
Therapist: Ah, okay, that hit you right here. [Mirrors participant move-
ments] Something deep is moving inside.
Client: Yes, deeply moving in places I can’t really see [motioning
between her heart area and lower abdomen area]. I know some-
thing is happening, because I feel the difference just sitting
here has made, but I can’t quite say why.
Therapist: Ah, so there is something here that can’t quite say why
[mirroring her movements]. [Long pause, perhaps a full minute;
therapist notices what appears to be a calmness in the client’s
facial features, but chooses not to mention that.] And if you
didn’t have to say why this is happening, this tectonic shift-
ing deep inside, what would you have then?
Client: I’d have me. I’d have me having cancer and having some
sense of it all moving, not stuck, moving. I’d have ME mov-
ing. [Client rests back in her chair, bringing her hands to her face,
not clawing, but holding her own head.]
Therapist: You’d have you . . . you moving.
Client: Can I just be quiet here for a while now? I want to take this in.
Therapist: Of course. I’ll wait here for you.

For this woman, it was not only the revelation of tectonic moving
(noted in the client’s saying “ME moving”) that was important. In addi-
tion, it is her own request for space in which perhaps the next new step
that appears valued comes. The client’s belief in her agency to choose her
own response to challenges is buttressed by also recognizing the importance
of actually allowing herself to feel the whole range of emotions that come
with this diagnosis.
In a later therapy session, this client is at a deeper level of experiencing,
as the transcript demonstrates.
Client: Too many things . . . there are just too many things I have to
keep track of now. I’m getting overwhelmed by the meds and
the scheduling. . . .
Therapist: This seems pretty important to you, the overwhelm you feel
with all of the things you need to track now. How about we
just make some space for this?
Client: Yes, sure . . . I think that would be a good thing.
Therapist: Then let’s take a moment now to just let your attention set-
tle down inside. Is that okay . . . er, possible, or do you need
some help in that?
Client: No, I can do it . . . hmm, let me see [closing her eyes and folding
her hands in her lap].
Therapist: I’m just going to wait for you quietly here; let me know if you
need something from me.
Client: [After a few moments of silence] Well, it feels crowded inside . . . 
like all whirling around . . . and I’m just almost bombarded
by it all.
Therapist: So there’s a crowded feeling, like a whirling going on
inside . . . and a sense of something like bombarded. . . . Did
I get that right?
Client: Yep, but it’s changed now, just now it seemed to shift or
something. It’s different.
Therapist: Different?
Client: Well, kinda now more like bombarded isn’t quite right . . . the
whirling is still going on.
Therapist: So, whirling inside is still there, it’s just that it isn’t so much
a bombarded feeling now.
Client: Right, not bombarded . . . still whirling. Like I’m not so
overwhelmed either.

Therapist: And is this someplace you could stay a little while and keep
company?
Client: Yes, I could do that. It’s even calmer now, too.
Therapist: It’s even calmer. So, let’s pause here for a moment or so, just
keeping that company.
In this part of the session, the client is self-directing much of her own
processing about the manner in which her life has changed since her cancer
diagnosis. The therapist is a guide whose job is only to assist her at this point.
She is following her own feeling of it all inside, and even though she is not
using overt body-focused words (e.g., tingly, funny in my gut), it is clear she is
feeling the whirling and later the sense of being more calm inside that arose.
Her own microprocess has led to shifting the way she is experiencing her
inner life.
The evidence from studies on experiencing level, focusing manner,

clearing a space, and the case studies presented here represents a continued
effort by FOT researchers to understand further the role that depth of expe-
riencing plays in psychotherapy. Discovering the personal meanings and the
character of changed experience is, of course, important for clients, because it
assists them to move forward in their lives. FOT practitioners are now better
able to describe practice that is congruent with its philosophical and theoreti-
cal basis, an approach that remains deeply humanistic and that offers a way of
speaking about therapy that honors human experience and meaning-making.
As Katonah (2012) stated, “Scientific inquiry begins with differentiat-
ing human processes and looking for their contributions to human living”
(p. 138). Today, research on FOT includes specific topics important to the
practice of psychotherapy in general: working with dreams, the therapeutic
relationship, what assists recovery from illness, the influence on therapy of
the therapist’s own experiencing, and what helps clients improve their qual-
ity of life.
As stated earlier, today there are certainly fewer outcome studies on
FOT, though there is more research on microprocesses than in the past.
Legitimate questions can be raised as to why so few experimental studies on
FOT, particularly those with control groups, have been conducted of late.
Perhaps it is because of the wider use of process measures in general and,
as suggested by Gendlin (1986), because the correlation between a higher
experiencing level and positive psychotherapy outcome has already been suf-
ficiently established.

We note too that current and emerging process research on FOT has
used refinements to traditional methodologies that are typically based on
cause–effect principles. To this end, future evidence of the successes or limi-
tations of FOT will likely take the form of establishing shared definitions of
what constitutes the quality of attending and pausing and the ability to trace
patterns forward in one’s living over the course of many sessions. Finally,
although it is clear that FOT continues in the tradition of person-centered
humanistic psychology, it is also true that its renewed emphasis on examin-
ing psychotherapy by defining process variables is helping the field retain its
emphasis on lived experience and human dignity.
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9
EXISTENTIAL PSYCHOTHERAPIES
MEGHAN CRAIG, JOëL VOS, MICK COOPER, AND EDGAR A. CORREIA
Questions about the nature of human existence have puzzled the human
mind for millennia, for instance, “What is the meaning of my life?” “How
do I cope with my mortality?” (e.g., Greenberg, Koole, & Pyszczynski, 2004;
Tillich, 1952). For some people, these concerns may evoke such anxiety,
uncertainty, and crisis that they may experience severe psychological distress
(Yalom, 1980). People may be especially vulnerable to experiencing such dis-
tress when they are in boundary situations (Jaspers, 1925)—that is, when they
are confronted with issues about their very existence, such as the diagnosis of
terminal illness. Many forms of psychotherapy and counseling implicitly help
clients to address such existential concerns. However, one group of therapies
that explicitly claims to do this—and to help clients develop a deeper under-
standing of their lived existence within a close relational encounter—consists
of the existential approaches to psychotherapy.
http://dx.doi.org/10.1037/14775-010
S. Rubin (Editors)
283
Until recently, research on the outcomes and processes of these exis-
tential therapies has been relatively scarce. In other psychotherapeutic tradi-
tions, most notably cognitive–behavioral therapy, a wide range of studies on
the effectiveness and mechanisms of psychotherapeutic practice have been
carried out (see Lambert, 2013). But the positivist underpinnings of such
research mean that it has largely been rejected in the existential psycho-
therapy field, in which human experience is viewed as unique and irreducible
and therefore outside the realm of natural science inquiry (Cooper, 2003;
Spinelli, 2005). Hence, when research is undertaken, it tends to be based
on a human science paradigm, which prioritizes the subjective experiencing
of the individual (e.g., Giorgi, 1985). Extensive case studies have also been
written (see DuPlock, 1997; Yalom, 1989) that can give powerful insights
into clients’ experiences of existential issues and the existential therapeutic
journey (most commonly from the psychotherapist’s perspective), but they
have provided little by way of a systematic, critical evaluation of whether,
and how, existential psychotherapies may bring about positive change.
A previous review of the research in relation to existential psychotherapies
has provided the most comprehensive evaluation to date (Walsh & McElwain,
2002). In it, Walsh and McElwain (2002) reviewed the evidence in support of
key existential assumptions (freedom, intersubjectivity, temporality, and becom-
ing) and concepts (existential anxiety, guilt, and authenticity), providing a vivid
description of existential theory and practice. However, Walsh and McElwain
did not directly review the available evidence on the effectiveness of existential
therapies or the wider psychotherapy research findings bearing on the potential
effectiveness of this approach.
The aim of this chapter, therefore, is to provide the first comprehensive
review of the evidence for the effectiveness of existential therapies. We begin
with a definition of the existential approaches to psychotherapy before going
on to consider the main elements and forms of existential psychotherapeutic
practice. We then review the process-outcome research bearing on the effec-
tiveness of existential therapies before looking more specifically at evidence
from randomized controlled trials (RCTs) and other systematic methods that
directly evaluate their outcomes. In the final part of the chapter, we discuss,
and illustrate, the implications this evidence has for practice.
SCOPE OF EXISTENTIAL PSYCHOTHERAPIES
Although existential therapy is one of the oldest forms of therapeutic

practice, it remains one of the least well understood. This is often attrib-
uted to the philosophical underpinnings that define existential therapeutic
practices, which are themselves diverse and not always compatible (Cooper,
284 craig et al.

2003; Norcross, 1987). Furthermore, existential therapies do not have a com-
mon origin; rather, they evolved at different times in different geographical
locations over the course of the 20th century. Hence, a wide range of core
beliefs, values, or practices characterize this field, making it more appropriate
to talk of existential therapies rather than a single existential approach (see
Cooper, 2003).
Given this diversity, it should come as no surprise that there is no con-
sensually agreed-on definition or scope of practice. As Norcross (1987) wrote,
“Existential therapy means something to everyone, yet what it means precisely
varies with the exponent” (p. 42). Indeed, with its emphasis on subjectivity
and independence of thought, it may be that some existentialists would rail
against any consensual definition. Nevertheless, for the purposes of a review
of evidence, it is essential to define what can, and cannot, be considered an
existential approach to therapy.
In 2010, a network of leading existential psychotherapists, based pri-
marily in the United Kingdom, were consulted on the question of how to
define the existential therapies, with a view to developing inclusion criteria
for the review of existential therapeutic outcomes that follows. Debates were
wide ranging, particularly around the question of whether it was legitimate
to define existential therapies in phenomenological and relational terms; no
consensus was achieved. However, the definition of existential therapies that
emerged from this dialogue proved sufficient for the subsequent review and
analysis: Existential psychotherapies are therapeutic practices that explicitly
use the term existential to describe either the therapeutic intervention or the
focus of the therapeutic work and are based, primarily or wholly, on one or
more of the following assumptions associated with the existential school of
thought: (a) that human beings are oriented to, and have a need for, meaning
and purpose; (b) that human beings have a capacity for freedom and choice
and function most effectively when they actualize this potential and take
responsibility for their choices; (c) that human beings will inevitably face
limitations and challenges in their lives and function most effectively when
they face up to—rather than avoid or deny—them; (d) that the subjective,
phenomenological flow of experiencing is a key aspect of being human and
therefore a central focus for psychotherapeutic work; and (e) that human
experiencing is fundamentally embedded in relationships with others and
with the world (Cooper, Vos, & Craig, 2011).
On the basis of this definition, a range of therapies influenced by exis-
tential ideas, but that are not primarily or wholly based on them (and that
do not principally refer to themselves as existential therapies), were consid-
ered outside the existential psychotherapeutic scope. They included Gestalt
therapy, contextual therapy, person-centered therapy, psychodrama, and the
Soteria approach. Specific therapies included Daseinsanalysis (e.g., Boss, 1963);
existential psychotherapies 285

existential analysis, the British school of existential therapy, and existential–
phenomenological therapy (e.g., Van Deurzen, 2012); logotherapy (e.g.,
Frankl, 1986); existential analytical psychotherapy (e.g., Längle & Bürgi, 2007);
the existential–humanistic/existential–integrative approach (e.g., Schneider &
Krug, 2010); meaning-centered group psychotherapy, individual meaning-cen-
tered psychotherapy, meaning-centered intervention, meaning-making inter-
vention, and meaning-centered counseling (e.g., Breitbart et al., 2010); Lantz’s
existential psychotherapy (e.g., Lantz & Walsh, 2007); experiential–existential
group psychotherapy (e.g., van der Pompe, Duivenvoorden, Antoni, & Visser,
1997); supportive–expressive therapy (e.g., Classen et al., 2001); and cognitive–
existential therapy (e.g., Kissane et al., 1997).
NATURE OF EXISTENTIAL PSYCHOTHERAPEUTIC PRACTICE
Given the diversity of existential approaches to psychotherapy, we have

divided this section into two parts. In the first, we provide an overall descrip-
tion and analysis of the practices of existential psychotherapists, and in the
second we focus specifically on the practices of existential psychotherapists
associated with three predominant schools. As we show, existential practices
vary greatly, and Cooper (2003) suggested a range of dimensions along which
they can differ, including descriptive–explanatory, nondirective–directive, and
spontaneity–techniques. Drawing these together, Cooper (2012) suggested
that there is a basic “hard–soft” dimension across existential practices, with
the former referring to the more challenging, psychoeducational, existentially
derived practices and the latter to the gentler, relational, phenomenologically
based practices.
General Practices
As Van Deurzen and Adams (2011) wrote,

Existential therapists have traditionally steered clear of formulating their
approach in terms of the acquisition of skills or the application of particu-
lar techniques. They have always argued that technique and skills get in
the way of full understanding of what a person is truly occupied with. (p. 1)
Combined with the diversity of existential approaches to therapy, this makes
it difficult to pinpoint, at the most general level, a set of practices, methods,
or constructs that can be defined as existential. Here, as Mearns (1997) wrote,
“Skillful behavior is recognized but there is a reluctance to seek to break it
into smaller units lest the integrated quality is lost” (p. 109). This view holds
that the whole is more than the sum of its parts and cannot be reassembled
286 craig et al.

from those parts. A related assumption in the existential field is that skillful
behavior is inextricably tied to the personal and philosophical development
of the psychotherapist (e.g., Wolf, 2000), such that an emphasis on concrete
methods and practices overlooks the very essence of what it means to practice
in an existential way: to be the kind of person who can offer a philosophically
informed, existential relationship to another.
This reluctance to articulate concrete methods and practices, however,
has also had the consequence that existential work “has always remained a very
private and to some extent obscure and even arcane form of therapy” (Van
Deurzen & Adams, 2011, p. 1). It has also made it very difficult to research or
evaluate the existential approach, an increasingly common requirement for
funding and commissioning in the public sector. In recent years, therefore, a
number of texts have attempted to give more concrete guidelines to existen-
tial psychotherapeutic practice (e.g., Cooper, 2012; Schneider & Krug, 2010;
Van Deurzen & Adams, 2011). In addition, two recent studies have directly
examined the question of what existential psychotherapists actually do. These
studies built on the findings of Norcross (1987), who conducted the first survey
of existential therapeutic practices. The first of these contemporary studies,
led by Portuguese existential psychotherapist Edgar Correia (Correia, Cooper,
Berdondini, & Correia, 2015), invited existential psychotherapists from around
the globe to complete an online survey, describing the methods or practices that
they considered most characteristic of this approach. More than 1,000 exis-
tential psychotherapists from 48 countries responded, and their answers were
thematically analyzed. The second of these studies, by Sousa and Alegria
(2015), analyzed session recordings from the practice of four Portuguese existen-
tial psychotherapists using the Psychotherapy Process Q-Sort Manual. Although
this analysis is limited to a particular form of existential psychotherapy (primar-
ily influenced by the British school; see British School of Existential Analysis
section, below), it is the first study to give a direct indication of the actual
practices that are most characteristic of an existential approach.
Findings from these two studies were relatively consistent with those of
Norcross (1987), suggesting that the practices of existential psychotherapists,
as a whole, can be organized into four domains: phenomenological practices,
relational practices, practices that are informed by existential assumptions,
and methods associated with particular existential schools. We explore
the first three of these in this section and the last in the section on specific
branches of existential therapy.
Phenomenological Practices
Correia et al.’s (2015) survey suggested that the methods most character-
istic of existential psychotherapy fit within the domain of phenomenological

practices. Philosophically, phenomenology tries to focus on phenomena-as-
they-are—that is, to do justice to the totality of each phenomenon, be it
to other people’s or one’s own inner experiences (see Moran, 2000). In this
respect, the client’s subjective flow of experiencing is taken as the key ele-
ment of his or her being and thus as a central focus for psychotherapeutic
work. By focusing on this subjective flow, existential psychotherapists strive
to help clients gain deeper self-awareness and insight—making explicit their
implicit view of self, others, and world.
To illustrate this, we use the example of a young artist, Patrick, who came
to therapy to be more in control of his emotions and to feel better about
himself. In the first sessions of therapy, Patrick talked mainly about his father
and the difficulties in their relationship, but in Session 12 he disclosed that
things were also very difficult with his partner, Tom.
Patrick: It’s funny, you know, we’re . . . people around us look and
think that we’re the perfect couple. Like the perfect apart-
ment, the perfect relationship—when people come around,
there’s always a . . . we’re always light and happy and bubbly
to see people, but. . . .
Therapist: Yeah, yeah . . . go on. [The therapist invites the client to say more
about his experiencing.]
Patrick: It’s . . . you know, there’s a real sense in which it is all a mask.
It’s all just . . . there isn’t the kind of stuff with Tom that
you’d think that . . . I do love him.
Therapist: OK, but tell me what it is like for you . . . what’s it like for you
in the relationship. You seem to be saying . . . I get a sense
that what you’re saying is that it’s not what . . . it doesn’t
feel the same as how people see it. [This is an invitation to
Patrick to talk, in more depth, about his experiencing of the
relationship—and particularly that experiencing that may be
less reflected on.]
Patrick: It’s . . . you know, I’m like . . . I just feel really alone a lot of
the time. I can get . . . I get back from work or something
and he’s sitting there, he’s on his websites or something, and
I’m like, “Can we do something together? Please, just do
something.” It’s so. . . .
Therapist: It sounds like frustration. Are you really frustrated with him?
[The therapist invites Patrick to “unpack” (i.e., describe in greater
detail) his experiencing.]
Patrick: Yes, sort of. . . . Yes, I don’t know. It’s: “I’m here, and you’re
here, and we’re just so—there’s such a distance.”
288 craig et al.

Phenomenological practices, based on Husserl’s phenomenological
method, may be described in terms of three interrelated steps (Ihde, 1986;
Spinelli, 2005). The first of these is the rule of epoché, whereby we are urged to
set aside our initial biases and prejudices of things, to suspend our expecta-
tions and assumptions; in short, to bracket all such temporarily and as far
as it is possible so that we can focus on the primary data of our experience.
(Spinelli, 2005, p. 20)
In this example, then, the therapist—who was a heterosexually identified
man—worked hard to put to one side any assumptions he might have about
gay relationships and listen closely to Patrick’s experiences as Patrick described
them. Second is the rule of description, the essence of which is “describe, don’t
explain” (Ihde, 1986, p. 34). In the present example, we can see how the
therapist consistently invited Patrick to describe his feelings, thoughts, and
perceptions in increasing levels of detail—“What was it like?” “What did you
feel?” “Was it like this?”—rather than offering an interpretation or explana-
tion of what was going on. Finally, there is the rule of horizontalization, which
urges therapists to treat all of the clients’ descriptions of their experiencing as
“having equal value or significance” (Spinelli, 2005, p. 21). Subsequent to this
vignette, then, it was important for the therapist to explore with Patrick his
feelings of love toward Tom, as well as his feelings of frustration.
Respondents to Correia et al.’s (2015) survey also described a range of
phenomenologically based practices and attitudes that were associated with,
but went beyond, a strictly Husserlian method. Central here was the adoption
of an understanding stance toward the client. This stance has parallels with
the person-centered practice of empathy, which can be defined as “entering the
private perceptual world of the other and becoming thoroughly at home in it”
(Rogers, 1980, p. 142). An example of this is when the therapist says to Patrick,
“It sounds like frustration.” He has sensed this from Patrick’s tone of voice and
tried to communicate this to Patrick as a means of helping him deepen his
self-awareness. This empathic sensitivity and attunement to the client also
emerged as the most characteristic feature of existential psychotherapy prac-
tice in Sousa and Alegria’s (2015) Q-sort analysis. Moreover, Norcross (1987)
found that Rogerian skills, such as being empathic, were the most commonly
reported practices of existential psychotherapists. Respondents also commonly
stated that hermeneutic practice was characteristic of their work, referring to
an interpretative, iterative process in which therapist and client work together
to analyze what is present (Van Deurzen & Kenward, 2005, p. 92).
Relational Practices
Data from Sousa and Alegria (2015), Correia et al. (2015), and
Norcross (1987) have suggested that a second common set of existential
psychotherapeutic practices constellates around the establishment of an

in-depth, authentic therapeutic relationship, along with reflection on, and
analysis of, the relational encounter. This emphasis on the client–therapist
encounter draws from the existential relational philosophy of Buber (1947,
1958), who argued that it is in the in-depth encounter between two human
beings that an authentic personhood is found. In this respect, a wide range
of existential psychotherapy texts (e.g., Boss, 1963; Spinelli, 1997; Yalom,
1980) have placed the psychotherapeutic relationship at the heart of exis-
tential practice.
Correia et al.’s (2015) analysis identified four main categories of relational
practices within existential psychotherapy. The first involves adopting a rela-
tional stance to the client and the therapeutic work—that is, being present
and caring and encountering the client in a way consistent with Buber’s (1958)
I–Thou attitude (see From Research to Practice section, below). Second is
addressing what is happening in the therapeutic relationship, through working
in the here and now, being aware of one’s reactions to the client, and disclos-
ing one’s experience in the room. For instance, around Session 15 in the work
with Patrick, it became evident that his difficulties with both his father and his
partner were related to his feeling that he always had to give in a relationship,
such that he became frustrated because his own needs were not being met. The
therapist was becoming increasingly aware that Patrick always seemed keen to
give to him, too, such as by bringing in paintings as presents, offering to make
the tea, and dutifully filling out outcome questionnaires. In Session 20, the
therapist decided to raise this issue.
Patrick: I . . . I think that . . . it’s like I’m always . . . I’m always
doing so much around the house and things for Tom. Like
he doesn’t . . . I don’t think he’s ever washed the dishes in . . .
just forever. He’s very sweet about it and all but I just. . . .
Therapist: You end up doing it. And do you . . . What would it be like if
you didn’t? If you asked Tom to do some of the washing up?
Patrick: I just . . . I know. Yeah, yeah [smiles], I should, but . . . I think
I’d feel too . . . guilty. Like I see it as my role, and if I’m
not . . . if I’m not doing things, then why would Tom be
with me? I think it’s . . . you know, we talked a lot about me
having a deep sense of just being fundamentally warped,
and I think . . . I guess it’s a way of catching up with him.
Of being okay in the relationship.
Therapist: You have to do that to make up for not being okay? To
compensate for. . . .
Patrick: Yeah, uh huh. So I’m . . . I guess, loved, wanted, not such a
fucking waste of space.
290 craig et al.

Therapist: And I . . . like, I guess I notice how helpful and giving you
are to me. Like that painting . . . you know, that’s . . . they’re
really lovely and I loved them, but . . . I guess . . . you know,
I do wonder if there is something here about also feeling
like you have to give to me to feel valued. Like if you don’t
give me something . . . you are already paying me . . . then
you . . . like you have to do that to compensate for who you
basically are.
Patrick: I . . . uh huh. . . .
Therapist: And I guess the thing . . . you know, the thing for me is that
I really . . . I do find it really engaging and valuing being with
you, and I . . . I know . . . you know, I’ve said this, but I like
you as a person, I find you engaging, and I really appreciate
how much work you put into this and . . . you know, that’s
fine, Patrick. You pay me for the therapy, and it’s also really
engaging for me to spend time with you and . . . you know,
you don’t need to do more than that. And I think that would
be quite a challenge to you to . . . you know, next time, you
don’t need to offer to . . . to put on the tea. If you want to,
great, but it’s . . . it’s really just fine us being together.
Here the therapist challenges Patrick’s way of relating to others through
a positive self-disclosure, but in a way that strives to maintain a supportive
and encouraging therapeutic alliance. The aim is to help Patrick develop his
awareness of how he is in relationship with others and to find ways of relating
that are more satisfying and fulfilling for him, and more authentic.
A third set of relational practices consists of relational skills—in particu-
lar, therapeutic listening. In the fourth, as indicated above, existential psycho-
therapists have described a set of practices that are essentially concomitant with
a person-centered approach to psychotherapy, including striving to maintain
an equal-power relationship and holding an attitude of unconditional positive
regard, as indicated in the above vignette.
Practices That Are Informed by Existential Assumptions

Around 20% of the responses in Correia et al.’s (2015) survey referred
to “practices informed by existential assumptions.” Most commonly, this
involved helping clients to “address the existential givens”—in particular,
freedom, choice, and responsibility; the anxiety and uncertainty of being; and
being-in-the-world with others. An example of this comes from Session 21
with Patrick, as he continued to explore his tendency to always give in rela-
tionships. Here, the therapist introduces the existential assumption that people
always have choices regarding how they act.

Patrick: And I could . . . I thought . . . I had you in the back of my
head [laughs], and I thought, I should probably say to him to
do . . . that this time he should do some plates, but I. . . .
Therapist: What happened, what went on for you? [another example
of inviting the client to phenomenologically unpack his or her
experiencing]
Patrick: I just looked at him and I thought [pause] . . . mmm . . .
actually, you know in some . . . I think I just . . . felt really
scared. Really. . . .
Therapist: Can you take me through it? So you were standing. . . .
[phenomenological unpacking]
Patrick: I was sitting, we’d eaten, he said something about watching
TV, and I thought, “I should say something,” but . . . I didn’t
[laughs]. I did feel really nervous about it.
Therapist: But . . . so you didn’t . . . you decided not to say anything.
[Here the therapist introduces the idea that Patrick had some
choice at this point.]
Patrick: I didn’t . . . yeah, I guess so, I just thought, “He’s so. . . .”
Therapist: He’s so . . .?
Patrick: I just got . . . felt really scared.
Therapist: But there’s . . . I guess what I’m thinking is that I can . . .
I can really sense . . . you know, you felt scared. But there
was also a kind of decision there, wasn’t there? You know,
you decided . . . you chose not to say anything. There is . . .
there’s some kind of choice there, I suppose.
Patrick: I didn’t want to. . . .
Therapist: And I guess . . . you know, I don’t . . . I’m sorry if . . . I don’t
want to sound harsh but . . . you know, in a way, at that point,
you’re choosing not to say something . . .
Patrick: Mm-hm . . .
Therapist: And in a way . . .
Patrick: Yup, yes . . .
Therapist: You’re also kind of choosing to carry on with that . . . with
you doing things for him. Like I know . . . I know it’s really
difficult to not, but you do . . . you’re not compelled to go
along with it. You could . . . there’s always, isn’t there . . . in
a way, there’s always a choice
292 craig et al.

Patrick: Mm hm, I. . . .
Therapist: And I guess the question here . . . there is, like, what is the
choice you want to make? You know, I don’t want to sound
like . . . there’s no right choice, you know; maybe you do
want to choose to do the dishes, but there is . . . you do, in a
way, need to accept that you are choosing, whatever you do.
[Here, the therapist challenges Patrick to consider the choices he
is making.]
Patrick: It’s really . . . it is definitely, really . . . it is tough.
Therapist: Yes, totally, you want to be . . . you want Tom to like you,
and . . . you also want to get more of what you want in the
relationship, and you’ve got to start . . . so, like . . . well. . . .
Patrick: Could I find some way . . . like, maybe, if we went out for a
drink and I tried to say some of it . . .
Compared with the phenomenological and relational practices described

above, the responses here are of a somewhat more directive and challenging
nature. Indeed, rather than bracketing assumptions, the therapist specifically
introduces a set of assumptions—albeit existential ones—into the therapeu-
tic work. Nevertheless, the aim is not to tell Patrick how he should act, but
to present him with an existential understanding through which he can find
a way forward for himself.
From the research (Correia et al., 2015), therapists also described a
range of practices that, more broadly, were focused on helping clients reflect
on—and address—their assumptions and ways of being at the deepest, most
existential level. This included clients’ worldviews, their ways of relating to
life, and their authenticity. Some respondents addressed these assumptions
in the context of Van Deurzen’s (2012) four dimensions of existence: the
physical world of things, the social world of others, the personal world of self,
and the spiritual world of values and ideas. From Sousa and Alegria’s (2015)
research, the second of these—the client’s relationship with others—also
seemed to be a principal focus of existential psychotherapeutic work, as we
have seen in the excerpts relating to Patrick. Specific existential philosophi-
cal concepts, such as Kierkegaard’s notion of dread, intersubjective theory,
or the hypothesis that “pain is unavoidable,” also underpin the practices
described by the respondents in this research.
Key Branches of Existential Therapy
The research discussed above gives a general overview of what exis-

tential therapists do. However, in practice, the work of existential therapists

tends to be aligned with particular branches of existential psychotherapy
practice, as listed above. In this section, we review the practices associated
with three of the most prevalent branches of existential psychotherapy:
meaning-oriented therapies, the existential–humanistic approach, and the
British school of existential analysis. Descriptions of practices are based on
the available literature, rather than on empirical data.
Meaning-Oriented Therapies
These forms of existential therapy use meaning as their central organiz-
ing construct, drawing from empirical research on the psychology of meaning
(Wong, 1998). Their origins can be traced back to Viktor Frankl’s (1986)
logotherapy, which aims to help clients discover purpose in their lives and
overcome feelings of meaninglessness and despair. Logotherapy is grounded
in the assumption that “he who has a why to live can bear with almost
any how” (Frankl, 1984, p. 97). That is, individuals who are experiencing
psychological distress can still do things that feel meaningful and important;
moreover, encountering situations in this way may give people the strength
and resilience to cope with life’s hardships.
To help clients reflect on their meanings in life, logotherapy uses rel-
atively directive techniques (such as Socratic questioning and paradoxical
injunctions; Frankl, 1984, 1986). Although logotherapists do not tell their
clients what should be meaningful in their lives, they will actively stimulate
an exploration of past, present, and future meanings to help clients identify,
connect, or reconnect with potential sources of meaning in their lives.
Today, meaning-oriented therapies are among the most widely practiced
forms of existential psychotherapy (Correia, Cooper, & Berdondini, 2014),
with a number of recent developments emerging from Frankl’s (1984) original
work. Most prevalent is Längle’s et al.’s (2005) existential–analytic approach,
which broadens logotherapeutic principles to consider a wider range of fun-
damental conditions for a fulfilled existence: an acceptance of one’s being,
feeling that one’s life is good, and sensing that one has a right to be oneself. This
approach has also proposed a number of new therapeutic techniques, although it
tends to be less directive than Frankl’s original stance. Wong’s (1998) meaning-
centered counseling is another reformulation of logotherapeutic principles
that integrates a focus on meaning with evidence and principles from positive
psychology and cognitive–behavioral practice. A third new form of individual
meaning-oriented practice is the meaning-making intervention (e.g., Henry
et al., 2010), based on Folkman’s theory of meaning-making as a coping strat-
egy (Park & Folkman, 1997). This therapy aims to help clients who have been
diagnosed with cancer reconcile shattered assumptions about self-worth as
well as the controllability and fairness of life events.
294 craig et al.

In recent years, a number of group-based meaning-oriented therapies
have also emerged. For instance, meaning-centered group psychotherapy,
developed by Breitbart et al. (2010), is a manualized structured intervention
that focuses directly on meaning-centered coping strategies, actively engag-
ing participants in deepening experiences to explore sources of meaning in
their lives, but also providing concrete explanations and practical guidelines
for coping with life-changing experiences.
Existential–Humanistic Therapies
In the United States, an existential–humanistic approach to therapy
emerged under the leadership of Rollo May. In 1958, May coedited Existence:
A New Dimension in Psychiatry and Psychology (May, Angel, & Ellenberger,
1958), which brought the writings and practices of European existential and
phenomenological psychiatrists to the United States for the first time. Three
of Rollo May’s mentees have become prolific writers about the existential
approach in the United States: James Bugental (1965, 1978), Irvin Yalom
(1980, 1989), and Kirk Schneider (2008).
From an existential–humanistic perspective, people are understood to
experience psychological difficulties as a consequence of trying to defend
against deep-seated anxieties. In this respect, it can be considered similar
to a classical psychoanalytical perspective (e.g., Wolitzky, 2003). However,
from this existential–humanistic standpoint, what creates people’s most basic
fears is their knowledge of the unavoidable givens of life—in particular, their
mortality, freedom, aloneness, and meaninglessness (Yalom, 1980). Hence,
existential–humanistic therapy tries to help clients overcome problematic
defenses and meet the anxieties of existence with an attitude of decisive-
ness and resolve (Cooper, 2012). Therapeutic strategies are primarily expe-
riential, ranging from the gently exploratory to the highly confrontational,
often oriented around an exploration of the dynamics of the therapeutic
relationship.
In recent decades, Yalom’s (1970) work on group psychotherapy, com-
bined with his articulation of an existential–humanistic standpoint (Yalom,
1980), has led to the development of a range of group-based psychotherapies
for people experiencing life-limiting illnesses. Supportive–expressive therapy
was designed by Spiegel and Yalom (1978) as a relatively unstructured, sup-
portive therapy for the treatment of cancer patients. It aims to foster sup-
port among members, facilitating expression of emotion about cancer and its
effects on their lives (Bordeleau et al., 2003). Discussions are oriented around
themes such as fears of dying and death, an examination of life goals and life
priorities, and the integration of a changed self and body image (Classen
et al., 2001). The impact of terminal illness on personal relationships is also

a focus, with the aim of improving support from, and communication with,
family, friends, and medical professionals (Spiegel, Bloom, & Yalom, 1981;
Weiss et al., 2003). It is hypothesized that through such groups, clients
may experience a greater sense of universality—of being in the same boat
as others—that may reduce feelings of being alienated from humankind
(Yalom, 1970). The group may also evoke feelings of altruism, because indi-
viduals help themselves by helping others, generating feelings of self-worth
and reducing feelings of helplessness (Yalom, 1970).
Experiential–existential therapy (van der Pompe et al., 1997, 2001)
is an approach similar to supportive–expressive therapy, combining an
existential–humanistic approach with experiential interventions (Elliott,
Watson, Goldman, & Greenberg, 2003; Gendlin, 1996). In the palliative
care context, a person’s fundamental concerns are given focus, including fear
of death, existential isolation, autonomy versus helplessness and dependency,
and meaning (van der Pompe et al., 1997, 2001). Emotional expression is
facilitated through experiential processes such as body awareness and relax-
ation, and social isolation is reduced through the support offered by the mem-
bers of the group (van der Pompe et al., 1997).
Kissane et al. (1997, 2003) have developed cognitive–existential group
therapy for clients with early-stage cancer diagnosis, drawing on the supportive–
expressive group approach but combining the existential components with
cognitive reframing and the development of coping strategies. The interven-
tion is manualized and time limited (20 sessions), and it is designed around six
goal areas: promoting a supportive environment, facilitating grief over losses,
reframing negative thoughts, enhancing problem solving and coping, fostering
hope, and examining priorities for the future.
British School of Existential Analysis

The origins of the British school of existential analysis lie in the work
of R. D. Laing, a Scottish psychiatrist who drew on a range of existential and
phenomenological teachings to critique the psychiatric assumptions of his
day (Cooper, 2012). Laing never systematized his approach, but, in the mid-
1980s, a British school of existential analysis began to emerge that drew on
many of his writings and ideas. This development was largely driven by Emmy
Van Deurzen (1998, 2012; Van Deurzen-Smith, 1997), a clinical psychologist
originally from the Netherlands. Van Deurzen’s approach drew on a range of
philosophical insights—including some beyond the bounds of existentialism—
to help clients address the basic existential question “How can I live a better
life?” Her starting point was that life is an “endless struggle where moments
of ease and happiness are the exception rather than the rule” (Van Deurzen,
1998, p. 132) and that problems in living arise when people are reluctant
296 craig et al.

to face the realities of their imperfect, dilemma-ridden, and challenging
existence. Hence, the aim of existential therapy, for Van Deurzen (Van
Deurzen-Smith, 1997), is to help clients wake up from self-deception to face
the challenge of living head on, in the process discovering their talents and
possibilities.
Like Laing and Van Deurzen, most therapists in the British school of exis-
tential analysis adopt a primarily descriptive, non–technique-based approach
to therapy, in which clients’ difficulties are seen as problems in living rather
than mental illnesses (see Cooper, 2012). The British school, however, can be
considered a school only in the loosest sense of the word. In particular, in con-
trast to Van Deurzen’s (2012) existentially informed philosophical counseling,
Ernesto Spinelli (1997, 2005) has advocated a more exploratory, relational,
and phenomenological approach to practice, in which therapists are encour-
aged to bracket their beliefs and assumptions and engage their clients from a
stance of not knowing.
Through its training programs, conferences, and journals, the British
school of existential analysis has also influenced the development of existen-
tial psychotherapy training programs and institutes across Europe, including
those in Belgium, Denmark, Greece, Portugal, and the Baltics. Here, as with
Spinelli (1997, 2005), there is a particular emphasis on the development of
relational, phenomenological ways of working, alongside a consideration of
key existential themes through the writings of such existential philosophers
as Heidegger (1962) and Merleau-Ponty (1962).
SUMMARY OF MAJOR RESEARCH FINDINGS
As was the preceding section, this section of the chapter is divided into
two parts. In the first part, we look at the evidence from the field of psycho-
therapy research and psychology that bears on the general practices of exis-
tential psychotherapists. In the second part, we then look more specifically at
the outcomes of particular forms of existential psychotherapy, reporting on the
findings of a new meta-analysis of the effectiveness of existential approaches.
General Practices
As discussed at the beginning of this chapter, research into either the

general or the specific practices of existential psychotherapists has been rela-
tively limited. However, from the broader field of psychotherapy research,
much research has been conducted on the practices considered most charac-
teristic of existential psychotherapy.

Phenomenological Practices
Although the outcomes of specifically phenomenological methods
have not been evaluated, one practice closely associated with it—engaging
empathically with the client—has been the subject of extensive empirical
study (Elliott, Bohart, Watson, & Greenberg, 2011). Elliott et al. (2011), in
their meta-analysis of the data, identified 224 separate tests of the empathy–
outcome association, drawn from 57 different studies and encompassing a
total of 3,599 clients. Their principal finding was that the weighted cor-
relation (r) between levels of empathy and outcome was .30, indicating
that levels of therapist empathy account for around 9% of the variance
in therapeutic outcomes. On the basis of this analysis of the data, the sec-
ond American Psychological Association Task Force on Evidence-Based
Therapy Relationships (Norcross & Wampold, 2011) concluded that the
psychotherapist’s levels of empathy are a demonstrably effective element of
the therapeutic relationship.
Relational Practices
The emphasis within the existential therapies, particularly the British and
existential–humanistic schools, on the quality of the therapeutic relationship
is strongly supported by empirical research. As the American Psychological
Association Task Force concluded, based on the most comprehensive analysis
of the data to date, “the therapy relationship makes substantial and consistent
contributions to psychotherapy outcomes independent of the specific type of
treatment” (Norcross & Wampold, 2011, p. 423).
The aspects of the therapeutic relationship that have been found to
relate to positive outcomes are also closely associated with those practices
that are characteristic of existential psychotherapeutic work. Alongside empa-
thy, the therapeutic alliance—the degree of collaboration and bond between
client and therapist (Bordin, 1979)—has been identified as a demonstrably
effective element of the therapeutic relationship (Horvath, Del Re, Flückiger,
& Symonds, 2011). Levels of positive regard have been identified as a prob-
ably effective element of the therapeutic relationship (Farber & Doolin,
2011), and psychotherapists’ congruence has been named a promising ele-
ment of the therapeutic relationship, albeit with insufficient research to judge
(Kolden, Klein, Wang, & Austin, 2011; Safran, Muran, & Eubanks-Carter,
2011). Similarly, therapists’ capacity to repair alliance ruptures is also seen
as promising in this regard. A previous meta-analysis (Hill & Knox, 2002)
found that therapist self-disclosures were a promising and probably effective
element of the therapeutic relationship, particularly when they were positive
self-involving statements, such as, “I get a real sense of excitement when you
talk about your photography.” However, reviews of the evidence have yet to
298 craig et al.

support the value of specifically focusing on the here-and-now therapeutic
interaction (Orlinsky, Grawe, & Parks, 1994).
More recently, research has indicated that clients’ ratings of their ther-
apist’s presence—closely related to Buber’s (1958) concept of the I–Thou
stance—have been found to predict positively both session outcomes and
the quality of the therapeutic alliance, across both person-centered and
cognitive–behavioral therapies (Geller, 2013). Closely related is emerging
evidence that the degree of relational depth between therapist and client—
“profound contact and engagement between two people, in which each per-
son is fully real with the Other” (Mearns & Cooper, 2005, p. xii)—may be
a powerful predictor of therapeutic outcomes. Using her Relational Depth
Inventory (Wiggins, Elliott, & Cooper, 2012), Wiggins (2011) invited cli-
ents to identify a particular helpful moment or event in therapy and then to
rate how accurately 24 items associated with relational depth fit with this
experience. Wiggins then looked at whether relational depth was predictive
of positive therapeutic outcome, finding that it was, with depth of relating
accounting for a striking 10% to 30% of the overall outcomes. In other words,
the more that clients experienced relational depth at a particular helpful
moment in therapy, the more they improved (Cooper, 2013). A majority
of clients in Knox’s (2013) qualitative interview studies also indicated that
moments of relational depth had a significant positive impact, both immedi-
ately and in the longer term.
Consistent with an existential stance that emphasizes an authen-
tic, humanizing encounter, data from posttherapy client interviews have
also suggested that a key determinant of good outcomes in therapy may be
clients’ perception that the therapist genuinely cares for them (Bedi, Davis,
& Williams, 2005; Cooper, 2008; McMillan & McLeod, 2006). This is more
than just experiencing nonjudgmental acceptance; it is a feeling that the
therapist is genuinely interested in their well-being and willing to go the
extra mile for them. Similarly, in terms of presence and authenticity, what
many clients seem to indicate is that they value a therapist who can meet
them as a person, and not just in a professional role (Knox & Cooper, 2010).
Practices That Are Informed by Existential Assumptions

The specific effects of addressing existential issues have not been sys-
tematically studied. However, many different types of psychotherapeutic
interventions address existential issues to some degree—such as schema ther-
apy and acceptance and commitment therapy—and generally show positive
outcomes (e.g., Hayes, Luoma, Bond, Masuda, & Lillis, 2006). The effects
of directly examining existential concerns may, however, depend on the
needs of individual clients and the nature of their particular psychological

problems. Several studies, for instance, have suggested that certain groups of
clients, such as cancer patients and people in palliative care, have a strong
wish to speak explicitly about existential topics (e.g., Henoch & Danielson,
2009). This may be because a negative life event shatters their fundamental
assumptions and positive illusions that they have in daily life, such as invul-
nerability and immortality (Janoff-Bulman, 2010).
In addition, large bodies of psychological evidence have suggested that
certain stances toward the world—aligned to an existential outlook—are
associated with greater psychological well-being. Such evidence does not
directly prove that addressing these areas in psychotherapy is helpful, but
it does suggest that if clients can be encouraged to reflect on, address, and
transform such attitudes or behaviors, they may be able to achieve enhanced
psychological functioning. The first of these areas is that of authenticity,
where research has suggested that people who score higher on authenticity
measures have greater life satisfaction, higher self-esteem, lower depression
and anxiety, and fewer physical symptoms (e.g., headaches); they also behave
in more socially constructive ways (see Chapter 1, this volume). Second
is the area of interpersonal relationship, where an overwhelming body of
psychological evidence has suggested that individuals with close and con-
fiding relationships are more likely to experience higher levels of psycho-
logical and physical well-being, along with lower levels of mental illness (see
Chapter 1). Third is the area of meaning, with a range of studies suggesting
that people who experience their lives as meaningful, and who feel that they
are progressing toward their goals, experience greater well-being than those
who do not (Brunstein, 1993; Zika & Chamberlain, 1992). Fourth, several
studies have suggested that, the more their mortality becomes salient, the
more people become aware of what is meaningful to them (Greenberg et al.,
2004). An awareness and acceptance of one’s mortality may help one live
life more fully (Wong & Tomer, 2011), and a denial of death may lead to
inauthenticity (Becker, 1973).
Outcome Research Associated With Key Branches

of Existential Therapy
What evidence is there beyond the general psychotherapy research to

show that existential psychotherapies lead to improvements in psychological
health and well-being? To answer this question, we set out to review all avail-
able data on the outcomes of existential therapies (the EXIST project), sup-
ported by funding from the British Society for Existential Analysis (Cooper
et al., 2011). Our inclusion criteria were that the therapies being evaluated
should meet the definition of existential therapies given earlier and that the
studies should be conducted with adult clients, be published between 1970
300 craig et al.

and 2011, and use at least one robust indicator of psychological well-being or
distress (either qualitative or quantitative). Our initial article covered evi-
dence from the RCTs, using conservative measures to calculate average effect
sizes (e.g., we excluded studies with very large effects as outliers, although
their inclusion would have resulted in much larger effect sizes; Vos, Craig, &
Cooper, 2014). We report this here, along with some of the preliminary find-
ings from longitudinal and qualitative studies.
Meaning-Oriented Therapies
Research on the outcomes of meaning-oriented therapies has become
widespread in recent years (Vos et al., 2014), particularly in the care of patients
with chronic physical diseases. Our systematic review identified 25 studies
in which such an evaluation had been carried out. All studies examined changes
in meaning and purpose directly through such measures as the Purpose-in-Life
test (Crumbaugh & Maholick, 1964) and the Seeking of Noetic Goals test
(Crumbaugh, 1977).
Six RCTs investigated the effects of meaning-oriented therapies, four of
which were group interventions for cancer patients. These interventions sig-
nificantly increased positive meaning in life compared with either treatment
as usual (e.g., routine medical care) or other therapeutic interventions (e.g.,
counseling), with a moderate to large average effect size (d = 0.64, p < .01,
n = 5 studies). The level of psychopathology was also significantly reduced to
a moderate extent (d = 0.47, p < .05, n = 2), self-efficacy increased moderately
(d = 0.48, p < .05, n = 2). However, one study examining physical well-being
did not find significant effects (p > .05, n = 1). In the 19 non-RCT studies
that assessed the effects of meaning-oriented psychotherapy, similar effect sizes
were found: moderate to large positive effects on meaning in life (d = 0.65,
p < .01, n = 10), reduction of psychopathology (d = 0.40, p < .05, n = 2), and
self-efficacy (d = 0.71, p < .01, n = 2). Similar findings were seen in two sys-
tematic qualitative case studies (Rogina & Quilitch, 2006, 2010) and in three
studies with a qualitative component (Lantz, 1996; Lantz & Gregoire, 2000;
Lee, Cohen, Edgar, Laizner, & Gagnon, 2006).
Thus, the analysis of RCTs, non-RCTs, and qualitative studies seems
to suggest that meaning therapies can help clients to a moderate to large
extent to experience life as meaningful, to increase their self-efficacy, and to
reduce their symptoms of psychopathology. However, more research is needed
because all effects were measured only immediately after the intervention (just
one study showed moderately large effects on long-term improvement related
to meaning in life; d = 0.57, p < .01), and the samples and control groups were
limited (small samples, with mainly group therapies for cancer patients, and
mainly care as usual as control).

Existential–Humanistic Therapies
The EXIST review identified a number of studies that, based on
existential–humanistic principles (Spiegel & Yalom, 1978), evaluated
the effectiveness of group-based interventions for clients with cancer
and other physical health difficulties. These included studies examining
supportive–expressive group therapy, experiential–existential therapy, and
cognitive–existential group therapy. The principal outcome measures were
psychological symptoms, primarily mood disturbance and anxiety, and the
results for each approach are described below.
Supportive–Expressive Group Therapy

Five RCTs investigated the outcomes of supportive–expressive group
therapy, primarily for cancer patients, compared with either care as usual (e.g.,
routine medical care) or other therapeutic interventions (e.g., counseling).
These interventions demonstrated significant but small effects on changing
symptoms of psychological distress (d = 0.18, p < .01, n = 6) and increasing
self-efficacy (d = .11, p < .05, n = 1) with small and nonsignificant follow-up
effect sizes (p > .05). A few studies have also examined changes in experience
of pain and physical well-being (e.g., Goodwin et al., 2001) but, again, found
small effects that did not reach statistical significance (p > .05). Consistent
with the RCT findings, pre- to postpsychotherapy changes observed in this
group of interventions were small and frequently nonsignificant.
Researchers of this intervention have offered a number of explana-
tions for this lack of supportive findings. First, they have suggested that the
outcome measures may not match the aims of the intervention (Bordeleau
et al., 2003). More specifically, most studies measured changes in mood,
which is transient and may not be the most appropriate gauge of long-term
psychological improvements (Classen et al., 2001). Second, there may be
difficulties in determining for whom the intervention is best, suggesting
that supportive–expressive interventions may not suit all clients. Here,
level of distress and length of diagnosis have been proposed as possible
moderating factors (Classen et al., 2008). Third, the small effect sizes may
be due to low baseline levels of distress in participants and the consequent
floor effects.
Experiential–Existential Therapy
One RCT (Barren, 2005) and one pre–post single-group-design study
(De Vries et al., 1997) investigated the psychological outcomes of experiential–
existential therapy for those diagnosed with a malignant tumor. Participant
numbers in the studies were low, and changes in depression as an outcome
302 craig et al.

were very small (d = 0.09). For self-efficacy and physical well-being out-
comes, changes were nonsignificant. A qualitative subanalysis of 20 partici-
pants showed positive psychological responses when session reports were
evaluated for coping style, autonomy, depression, loneliness, and meaning
in life. Those with better outcomes indicated healthier coping styles from
the start: fighting spirit and some denial, less depression before being diag-
nosed, and almost no feelings of guilt about getting cancer (De Vries et al.,
1997, p. 135).
Cognitive–Existential Group Therapy

Findings for cognitive–existential group therapy (Kissane et al., 2003)
are similar to those for supportive–expressive group therapy and experiential–
existential therapy. This study did not show any significant findings compared
with the control intervention, although several trends (.05 < p > .10) were
found for a moderate positive effect on psychopathology and family dysfunc-
tion, though this may be due to problems in the study design and statistics
(Kissane et al., 2003).
British School of Existential Analysis

Scholars associated with the British school of existential analysis have
focused almost exclusively on qualitative and phenomenological research
methods, with a complete absence of controlled research. Recently, however,
a small number of longitudinal and case studies have been conducted on the
outcomes of existential therapies being delivered by the United Kingdom’s
National Health Service, where the pressures and demands for evidence-
based practice are felt most acutely.
The one study meeting inclusion criteria for this review used Elliott’s
(2001) hermeneutic single-case efficacy design to evaluate the outcomes of
existential therapy (Craig, 2011). The client had sought therapy for anxiety,
depression, and anger difficulties, and the intervention aimed to support her
through a process of phenomenological exploration, with a view to reframing
her sense of meaning and ways of coping with life events. At the end of therapy,
reliable clinical change was shown on all measures (Personal Questionnaire;
CORE Outcome Measure 34 items; Beck Depression Inventory), with signifi-
cant reductions in the client’s self-identified problems. Through qualitative
interviewing, the client also reported that the changes she had experi-
enced were both surprising and unlikely to have occurred without therapy.
The positive and negative evidence for change was evaluated against a
number of specified criteria (Elliott, 2001), and the quasi-judicial adju-
dication procedure determined that the client had changed as a result of
the therapy.

Summary of Key Findings
Data from the wider field of outcome and process-outcome psychotherapy
research have suggested that existential psychotherapeutic practices should
be of benefit to clients. Here, many of the key elements of existential psycho-
therapeutic practice have been found to be predictive of positive therapeutic
outcomes—in particular, an empathic, caring, and collaborative relationship
that can help clients reflect on and deepen their understanding and experienc-
ing of their lived existence. Yet when the outcomes of existential approaches
to psychotherapy are specifically evaluated, a more mixed picture appears.
Meaning-oriented psychotherapies—using a relatively structured format—do,
indeed, seem to help clients develop a greater sense of meaning, as well
as leading to other improvements in mental well-being. The evidence for
other existential interventions, however, has suggested small, and often
nonsignificant, effects across a range of well-being indicators.
At the same time, these latter findings must be understood within the
context of several important limitations. Nearly all of these interventions
were delivered in a group format, which may have diluted their effectiveness.
Severity of distress may also have had an impact on effectiveness, although
it is not clear whether this is the result of studies with clients having low
baseline distress such that further intervention did not have measureable
impact or more a result of those studies in which baseline distress was very
high and the treatment was insufficient in length or focus. In addition, the
outcome measures may not have reflected the key dimensions along which
such interventions as supportive–expressive therapy may have helped clients.
Furthermore, these studies have evaluated only a very narrow range of exis-
tential therapeutic practices, with a similarly narrow range of client groups.
Hence, the specific outcomes of existential psychotherapies, as often prac-
ticed in the world today (Correia et al., 2014), have been inadequately tested.
For now, therefore, the most appropriate conclusions from the evidence
may be as follows. First, although evidence is lacking for the effectiveness of
most existential therapies, the relational and phenomenological principles
on which they are based, as well as the ubiquity of the equivalent outcomes
paradox across all psychotherapies (Wampold, 2001), suggest that they may
well bring about positive therapeutic outcomes at a magnitude similar to
that of other humanistic and relational psychotherapies. Second, meaning-
oriented group therapies, using a relatively structured approach, seem to be
an effective means of bringing about increases in meaning and other forms of
psychological well-being for people who are facing severe health crises. Third,
supportive, experiential, and relatively unstructured group interventions for
people facing severe health crises, oriented around existential themes, seem
to be of only small benefit in reducing psychological distress, though there
may be other, as yet untested, ways in which they are of benefit.
304 craig et al.

On the basis of the empirical evidence of what works in existential

psychotherapy, we discuss, and illustrate in more detail, two key aspects of
existential practice. These aspects are working at a level of deepened thera-
peutic relating and helping clients to find meaning in their lives. Both of the
client examples presented here also illustrate other key aspects of existential
psychotherapy, such as working phenomenologically and helping clients to
face the existential givens of their lives.
A Deepened Therapeutic Relationship
On the basis of Buber’s (1958) concept of the I–Thou stance and a range
of existential writings (e.g., Yalom, 2001), Cooper (2015) suggested eight prac-
tical strategies psychotherapists can use to enhance the possibility of a deep-
ened therapeutic encounter. The first is to try to stand alongside clients as a
“fellow traveler” (Yalom, 2001) rather than surveying, studying, or analyzing
them. Second is to relate to clients as subjects rather than as objects, to engage
with them as a source of agency and experiencing. Third is to acknowledge
clients’ capacities for freedom and choice—to engage with them as someone
who is responding to their world, rather than determined by it. Fourth is to lis-
ten to clients holistically and in an embodied way, breathing in and responding
to the totality of their being. Fifth is to be open to the otherness of clients—to
put one’s assumptions about who clients are to one side and meet them from a
place of indefiniteness and unknowing. Sixth is to affirm clients, but to do so
from a place where the psychotherapist holds onto his or her own difference,
rather than attempting to merge with them. Seventh is relating to clients as
wholenesss, bringing one’s own totality into the encounter. This means relating
in both affective and cognitive ways, and being willing to bring such aspects of
oneself as one’s vulnerabilities into the therapeutic meeting. The final strategy
is a willingness to take risks, to allow oneself to be changed in the meeting with
the other and let go of one’s certainty of and security in what one know.
An example of such practice comes from the work of the fourth author,
Edgar Correia, with a psychiatric outpatient who had spent 3 days at home,
isolated, before the session. The young man, in his early 30s, arrived with a
desperate and anxious look. For 15 minutes, the client, Viktor, told his thera-
pist how sad, desperate, and lonely he was feeling.
Viktor: I can’t see any solution! I’ve reached my limit! I don’t think
I can take this much longer. . . . I’m so completely scared.
[The therapist nods, feeling and receiving Viktor’s pain.] I think
again and again about going home . . . with no one waiting
for me, no one there for me. I’m so afraid of not being able to

stand that empty house . . . of burying myself in my depres-
sion again or even just ending my life. . . . The loneliness just
feels enormous! I feel so alone. . . .
Therapist: [Deeply touched and wanting to be a support to Viktor] Is there
any way that I can be with you in these difficult times?
Viktor: Yes, but you’re only here once a week. You can’t be with
me all the time. And even if you tried to, I know I’d push
you away. I push people away from me, like I did with Sofia
[former girlfriend]. Because when I feel like this, I feel like a
monster and push everyone away. [Silence] But now I feel so
lonely . . . I need someone to hug, who cares for me. . . . But
I can’t ask for help . . . and even when people try and help
me, I reject it . . . I feel so lonely . . . nobody to hug me. . . .
Therapist: [Spontaneously] Can I give you a hug?
At this point, Viktor looked at his therapist with a stunned expres-
sion. The therapist got up from his chair and walked toward Viktor, who got
up and burst into tears. They embraced warmly, and Viktor wept copiously
on his shoulder. When they returned to their seats, Viktor continued to cry
intensely for several minutes, and his therapist’s eyes also moistened. Finally,
with a much calmer face and an ambiguous smile, Viktor said,
You’ve really screwed me with this hug. . . . [his therapist looks surprised] I
really felt that you were here with me, that I wasn’t alone. You screwed
me, because now it doesn’t feel legitimate to close myself at home
because I’m lonely.
In this vignette, the therapist illustrates what it means to stand alongside
clients in a nondiagnostic way, taking in the totality of his own being at an
affective, as well as cognitive, level. There is an openness to Viktor as he is in
that moment, and a willingness from the therapist to respond in a spontane-
ous, unmediated, and deeply human way to Viktor’s suffering. The therapist
hugs Viktor, and in that action Viktor seems to reconnect with a deep thread
of humanity that has been missing in his life. It is a moment of relational depth
that challenges Viktor to stay in connection with others and to retrieve his
authentic being-in-connection.
Meaning-Oriented Practice
The outcome research in the existential literature has suggested that

meaning-oriented practices may be particularly effective contributions in
helping clients find greater well-being. Several meaning-oriented interven-
tions start with psychoeducation about the possible sources of meaning in life.
306 craig et al.

These sources tend to be drawn from Frankl (1984, 1986) and are described
by Breitbart et al. (2010) as follows:
77 meanings from connecting emotionally with life—for instance,
via relationships, humor, beauty, or music;
77 meanings from actively, creatively, and productively engaging
in life—for instance, via work, accomplishments, and respon-
sibilities;
77 meanings from changing one’s attitudes toward circumstances,
challenges, and life’s limitations—for instance, turning per-
sonal tragedy into triumph; and
77 meanings from reviewing past achievements, current ways of
living, future legacy, and the wholeness of life.
Here, therapists explicitly convey their conviction that anyone can recon-
nect with meaning in life, even though clients themselves may not see these
sources. Breitbart et al. (2010) addressed one source of meaning in each of the
sessions, and Lee (2008) explicitly integrated the sources into the sessions.
Meaning-oriented therapists may also use experiential exercises to examine sys-
tematically the client’s experiences with one concrete source of meaning. Later
on in a session, phenomenological methods may be used to help clients explore
further and listen to their lived experiences, thereby uncovering the sources of
meaning that are presumed to lie dormant within such experiences.
An example of such manualized meaning-oriented practice comes from
the work of the second author, Joël Vos, with a 43-year-old woman, Lauren,
who had been through treatment for breast cancer. Lauren and Joël started
the session by talking about how she coped with limitations in her daily life,
such as not catching the bus and being late for therapy. During this discus-
sion, Joël asked her how she managed other concrete limitations in daily life,
using this as a means of introducing attitudinal sources of meaning.
Therapist: I wonder if we could talk about limitations today. Some cli-
ents have told me that, when they develop cancer, they start
to think about the limits of life, such as death and feeling
really vulnerable. I can really imagine someone thinking
about that during treatment, and also for a long time after-
ward. Is that something you’ve been thinking about?
Lauren: Of course . . . especially in the weeks just before my annual
breast screening. I really can’t sleep. I just think about the
possibility that it’s back . . . and that I die . . . I can see myself
dying. So much pain, my children will miss me. . . . [Lauren
is obviously experiencing a lot of anxiety. She looks to be in pain
and is nervously caressing her hands. The therapist decides to
acknowledge this feeling and to explore it phenomenologically.]

Therapist: I can see that thinking about dying is very stressful for you.
[Silence] If it’s okay for you to stay for a moment with this
feeling, could you describe to me what you are experiencing
right now?
Lauren: Sadness . . . not seeing my kids growing up and getting chil-
dren themselves . . . anxiety, uncertainty. . . . [Lauren’s tone
changes.] You know, I shouldn’t be saying this. You know,
if you open up a newspaper, it’s all about cancer patients
fighting like heroes, like Lance Armstrong, who beat cancer
and then won the Tour de France. That’s what your mean-
ing therapy is about as well, isn’t it, turning tragedy into a
meaningful experience? I can’t do that. I can’t get rid of it. I
just don’t think you can turn feeling scared and vulnerable
into feelings of triumph.
Therapist: Yes, I know, I don’t think we can change the limits of our
lives—we’re all mortal, and feeling vulnerable is inevitable.
They’re givens; you can’t change the reality of these feel-
ings. But at the same time there’s a second process that can
start, which is about experiencing meaning in life despite
them. I don’t know how you interpret that, but I believe
that you have just described how you continue to live your
life and take care of your children, despite all your fears.
What do you think—how have you been able to do that
despite your feelings?
Lauren: I think . . . it’s my children who give me the power. . . . And,
you know, I’m not the type of person who gives up: I’m per-
sistent, proud, stubborn—that’s what my mom called me as
a child.
Therapist: To me, that sounds very meaningful and actually quite
heroic. What’s heroic is not denying the limitations of life.
You can’t beat mortality and your feelings about it, but you
can enjoy your children, persevere, be proud: These are
really big achievements. That’s meaning in life . . . you don’t
need to look for it, it’s already there. Even though you feel
really scared.
After this exchange, Joël asked Lauren for specific examples of how she
finds meaning in her daily life despite her feelings. At the end of the session, they
discussed which concrete lessons Lauren could learn and apply in her daily life
as a result of reflecting on the unchangeable limitations of life such as mortality.
These exercises helped to move the session away from a more theoretical level,
to concretize how she could find meaning in the midst of everyday life. Hence,
in this example, Joël used both phenomenological and more psychoeducational
methods to help Lauren identity sources of meaning in her life while at the same
time coming to terms with some of the key existential givens of being.
308 craig et al.

KEY AREAS FOR FURTHER RESEARCH
If existential therapies are to continue to contribute to the development

of psychotherapy, they may need to do so within the context of positivist
empirical research, because this gold standard looks set to stay for some time
(Cooper & Reeves, 2012). In part, this may involve undertaking further ran-
domized controlled studies, particularly for those many forms of existential
psychotherapy that have yet to be adequately tested. This may run counter to
many existential sensibilities, but, as Norcross noted (1987), “The exclusive
reliance on case histories and therapists’ impressions to support the efficacy
of existential psychotherapy” would seem “archaic” and “myopic” (p. 63).
Instead of taking a defensive stance on this, however, existential prac-
titioners should also recognize the opportunities afforded by the resurgence
of process research (see, e.g., Hilsenroth, 2013), which uses rich, qualita-
tive methods to understand how interventions have an effect at the level of
the individual rather than at the level of the average. Methodologies are no
longer seen in opposition to one another; the broad psychotherapy research
literature now acknowledges how both quantitative outcome methods and
more qualitative process methods complement each other in developing the
understanding of therapeutic practice (Cooper, 2008). This shift to human
science approaches and process-oriented research is the ideal canvas from
which existential practitioners and researchers can color the psychotherapy
landscape, bringing evidence for existential themes and practices that may
yield the greatest therapeutic effects in the wider arena.
Other areas for future inquiry include developing an understanding of
those client groups that may benefit most from existential therapies. There is
also a need to develop measures that can evaluate the process and outcomes
of existential therapies in ways that are intrinsically meaningful. For instance,
from an existential standpoint, the reduction of psychopathology is not nec-
essarily the most important clinical goal. Here, new creative methods may
be important developments, such as online tools or cognitive experimental
tasks (Greenberg et al., 2004), which can access deeper levels of existential
meaning and lived experiencing.
CONCLUSION
Joël’s work with Lauren is a good example of a more challenging and

directive approach to existential therapy, and Edgar’s work with Viktor
is a good example of a more gentle, phenomenological practice. From the
research, it would seem that much existential therapeutic practice falls into
the softer camp, with a frequent use of empathic, validating, and relation-
ally focused practices. This is well supported by the general process–outcome

psychotherapy research. However, our review of the outcome data has sug-
gested that the more directive practices may also have a very important place in
the pantheon of existential interventions, particularly those oriented around
finding meaning in life. These practices may make a particularly unique con-
tribution to the wider psychotherapy field by directing clients toward address-
ing the fundamental existential concerns at the core of their being.
Research points the way towards these possibilities and, in the existential
field, attitudes toward research are gradually improving. Existential therapies
dig down into the very essence of what it means to exist as a human being,
touching on intangible truths. Inevitably, then, when one starts to research
existential approaches—transforming them into quantities and generalities—
we inevitably sully them. Yet, without such exploration, there is a danger that
these elusive aspects become overlooked, and existential psychotherapies
end up trapped in their own assumptions and biases. In this respect, research
can lead to growth, evolution, and development—essential qualities for any
psychotherapeutic movement, particularly one that professes the importance
of bracketing, fluidity, and openness to change. Fortunately, however, at the
heart of an existential approach lies an acceptance of the paradoxical nature of
life: that there are contradictions in being that must be accepted rather than
resolved. Perhaps the relationship between research and existential practice is
one such paradox: Research can deaden practice as well as enliven it, support it
as well as squash it. Living in the midst of this paradox with passion and gusto
is what existentialists may be best at accomplishing.
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10
EMOTION-FOCUSED THERAPY
RHONDA N. GOLDMAN
Emotion-focused therapy (EFT) has its roots in the humanistic–

experiential tradition from which it emerged. EFT integrates Gestalt and
experiential theories, methods, and techniques into a client-centered core
relational foundation to help people change. EFT adapts modern construc-
tivist, attachment, and emotion theories to form both a conceptual under-
standing of human functioning and dysfunction and a model of therapeutic
change. EFT has also been informed and supported by recent advances in
the neuroscience of emotion. Research studies conducted in the past 30 years
have helped create support for the efficacy of the approach, establish the
relationship between change in emotion during therapy and a positive
outcome, and contribute to advances in the theory. In this chapter, I
briefly review that theory, tracing developments in EFT before turning to
a review of research studies including recent outcome studies as well as
http://dx.doi.org/10.1037/14775-011
S. Rubin (Editors)
319
those mapping the relationship between emotional change and outcome.
A case example is used to demonstrate theory and illustrate the implica-
tions of research findings.
THEORETICAL EVOLUTION OF EMOTION-FOCUSED THERAPY
EFT is firmly planted in the humanistic–experiential tradition. The begin-

nings of the therapy can be traced back to Laura Rice, a student of Rogers’s in the
1950s, and her involvement in psychotherapy research studies that attempted
to understand the client’s experience in the process of change. It was during
Rice’s time as a student that Rogers, Gendlin, and colleagues began to inves-
tigate the client side of the process equation, which was a shift away from the
focus on the facilitating conditions of accurate empathy, unconditional posi-
tive regard, and genuineness (Rogers, Gendlin, Kiesler, & Truax, 1967). This
productive phase of development led to the first client process scale (Walker,
Rablen, & Rogers, 1960) and then the Experiencing Scale (Klein, Mathieu,
Gendlin, & Kiesler, 1969); both eventually led to the practice of focusing
(Gendlin, 1982). This faction of the person-centered and experiential move-
ment eventually came to be called experiential; it resulted in a separation from
those therapists who continued to put the primary emphasis on the therapist
relational conditions (Elliott, 2012; Kirschenbaum, 2007). In the 1960s, after
Rogers left the Counseling Center at the University of Chicago, Rice stayed
on and directed it for a time. She was interested in and influenced by cognitive
science, which emphasized information processing; in collaboration with a
colleague, David Wexler, she continued to conduct client process studies that
investigated stylistic variables such as client expressiveness and vocal quality.
She also began to look at the evocative function of the therapist, through the
use of metaphor and vocal expressiveness (Rice, 1974).
In the next decade, now at York University in Toronto, Rice and her
then-student Leslie Greenberg, intent on studying client events, or episodes,
as an innovative way of understanding in-depth client process, became inter-
ested in a method called task analysis. Their colleague, Juan Pascual-Leone,
a neo-Piagetian cognitive scientist at York University, had introduced them
to this complex method that integrates theory with rigorous observation of
in-situation performances. Rice used the method to develop and study sys-
tematic evocative unfolding at client-reported in-session markers of prob-
lematic reactions, which was the study of how clients used a process of gentle
reexperiencing to resolve and make sense out of a puzzling personal over
reaction. Leslie Greenberg, who by that time had begun studying Gestalt
therapy (Perls, Hefferline, & Goodman, 1951), used the task analytic method
320 rhonda n. goldman

to map out the two-chair dialogue at client presentations, or markers of inter-
nal conflict that involved the enactment of the two conflicting aspects of self,
usually in the form of the critic (“top dog”) and a part that is being criticized
or pressured to do something (“underdog”).
The results of their studies were described in the book Patterns of Change
(Rice & Greenberg, 1984), which explicated a program for the study of observ-
able events or processes in therapy occurring at in-session markers evidencing
a particular state or problem space at a specific moment in time. So it was
that the events-based paradigm was born. This in turn had a strong impact on
the overall field of psychotherapy research, because it slowly shifted emphasis
away from generic outcome research that assumed that people would respond
to homogeneous treatments in a similar fashion to the intensive study of
contextual, specific events at recurring moments of change.
Rice and Greenberg later joined forces with Robert Elliott, who
offered his background as a therapy microprocess researcher studying ther-
apist response modes and client in-session experiences, along with a strong
interest in Gendlin’s (1982) focusing method (Elliott, 2012). They devel-
oped a number of task models, including systematic evocative unfolding
in response to a client-reported puzzling overreaction to either an external
or an internal event–the two-chair dialogue when two parts of the self are
in conflict or one is negatively self-evaluating the other–and experiential
focusing in relation to an unclear felt sense as well as the empty-chair
work for unresolved hurt, pain, or anger with a developmentally signifi-
cant other. They also studied the two-chair enactment, when one part of
the self is emotionally interrupting or suppressing another part, and the
empathic affirmation offered in response to a client revealing shame and
vulnerable feelings in the session.
A little later in his career, in collaboration with his then graduate stu-
dent, Susan Johnson, Greenberg integrated and applied experiential and
Gestalt theories, principles, and methods with a systemic approach that
resulted in the development of a couples therapy called emotionally focused
therapy; a book was subsequently published that included that name in its
title (Goldman & Greenberg, 2013; Greenberg & Johnson, 1988). Further
developments in EFT for couples were subsequently articulated in a more
recent book by Greenberg and Goldman (2008). It was becoming clear that
the term emotion-focused therapy was comprehensible, descriptive, and broadly
appealing. This was further clarified through the process of writing the book
Learning Emotion-Focused Therapy: A Process-Experiential Approach to Change
(Elliott, Watson, Goldman, & Greenberg, 2004), which was a collaboration
between Elliott and Greenberg as well as Jeanne Watson, a student of Laura
Rice, and Rhonda Goldman, a student of Les Greenberg (see also Watson,
Goldman, & Greenberg, 2007).
emotion-focused therapy 321

BASIC PRINCIPLEs
EFT, being a blend of client-centered, Gestalt, and experiential therapies,

retains many of the foundational principles of humanistic therapies. At the
same time, some of the original principles have developed and changed.
The foundational principles of EFT are explicated in the following sections.
The first three are those that have been retained; the neohumanistic prin-
ciples that have either evolved or been integrated are listed subsequently.
Humanistic Values and Principles
The humanistic values and principles of EFT are as follows:

1. Agency—Human beings are fundamentally free to choose what
to do and how to construct their worlds.
2. Wholeness—People are greater than the sum of their parts and
cannot be understood by attending only to single aspects.
3. Pluralism–equality—Differences within and between people
should be recognized, tolerated, and even prized.
Growth
People have a natural tendency toward psychological growth and devel-

opment that continues throughout the life span. This has been a hallmark
of the humanistic movement and is, indeed, a fundamental tenet of EFT.
The caveat is that, in EFT, the growth tendency is seen as being dialecti-
cally guided from both within and without. The internal aspect is guided
by the emotion system, which evaluates situations in relation to well-being
(Greenberg, Rice, & Elliott, 1993). The external aspect is seen as being
guided through interpersonal relating with the therapist.
Relational Presence of the Therapist
EFT emphasizes the importance of the client-centered (Rogers, 1951)

relational conditions of empathy, genuineness, and unconditional positive
regard as fundamental to the formation of a strong bond and a trusting rela-
tionship in which the client can disclose vulnerable emotions. In addition,
alliance formation is the first task of therapy, with the therapist working
with clients to establish mutual trust and a safe environment so that they
can engage in experiencing and exploring more painful experiences (Elliott,
Watson, et al., 2004; Watson & Greenberg, 1998). Alliance formation
unfolds through several successive stages, culminating with the achievement
of a productive working relationship.

EFT therapists have come to recognize and appreciate the inherent bal-
ancing act involved in maintaining a relational presence while at times engag-
ing in process guiding. When clients are in need of empathic resonance and
affirmation, it is important that therapists respond and provide it. However,
it is important for therapists to provide process guiding when the goal is to
deepen or shift emotional processing. This dilemma has been characterized as
a dialectic between leading and following, or being and doing, and it to some
extent reflects the duality of both the art and the skill involved in being a
strong therapist. Perhaps, above all, it is most important to be responsive and
interpersonally sensitive to the client (Greenberg, 2004).
Interpersonal support is fundamental in the process not only because of
the necessity of a strong bond, but also because the therapist can help peo-
ple to access their internal experience. This is key in the process of change.
Meaning is created by human activity, in dialogue with others, and people are
seen as creators of the self they find themselves to be. Change occurs through
the self-organization of a biologically based, emotionally guided growth ten-
dency, as well as from genuine dialogue between two people.
Although EFT is seen as a partial outgrowth of client-centered therapy
(Rogers, 1959) that emphasizes the inherent growth tendency within the
person, EFT, in its modern form, also recognizes the importance of the growth
that occurs through the client–therapist relationship. That is, support for the
growth process comes from the therapist, who sees the client’s coping efforts,
confirms and validates them, and focuses on possibilities and strengths. This
approach influences what is activated in the person’s internal experience. In
other words, growth occurs in an interpersonal field (Greenberg, 2010).
Constructivism, Dialectical Constructivism, and Coherence
EFT adopts a dialectical–constructivist epistemology (Greenberg &

Pascual-Leone, 2001) that applies to the theory of self as well as to the change
process, along with the interweaving of emotion and narrative processes
that occurs across therapy (Angus & Greenberg, 2011). Dialectical con-
structivism refers to a pluralist, neo-Piagetian perspective in which the pro-
cess of knowing changes both the knower and the known, therapy changes
client and therapist, the emotional change influences narrative change,
and vice versa. The self is viewed as a process made up of various elements
continuously interacting to produce experience and action. Multiple inter-
acting self-processes often take the form of emotion schemes. Different
voices or aspects of emotion schemes are usually represented in therapy
as two polar opposite voices, some dominant or salient, others implicit
or unacknowledged. The two voices are often characterized broadly as
internal and external or experiential and conceptual. Change processes

lead to a clear separation between the different self-processes or emotion
schemes.
Emotion
Emotion is fundamentally adaptive in nature, helping the person pro-

cess complex situational information rapidly and automatically to produce
action appropriate for meeting organismic needs such as self-protection or
self-support. Emotion is considered the basic datum of awareness, attended
to throughout therapy sessions (Greenberg, 2002). Emotion schemes provide
an implicit, constantly evolving, higher order organization of experience but
are not available to awareness until activated or reflected on. They are idio-
syncratic and highly variable, both across people and within the same person
over time. Although emotion schemes serve as the basis of self-organization,
they are not static entities: they are, instead, continually synthesized in peo-
ple’s moment-to-moment experiences (Greenberg & Pascual-Leone, 2001).
It is the experienced or felt emotion, however, that organizes all the other
elements around a particular emotion and its felt quality (e.g., intense sad-
ness, paralyzing fear).
Although emotions guide people and tell them what they need, which
makes it important to be aware of and attend to them, emotions can also be a
major source of dysfunction when things go wrong. More is said in the View
of Dysfunction section about how this occurs, but it is important to state that
not all emotion is seen as serving the same function, and therapists respond
differentially, depending on which type of emotion is presented. We distin-
guish among four different types of emotional experience and expression to
guide intervention.
Primary adaptive emotions are uncomplicated, direct responses consis-
tent with the immediate situation. As such, they help people take appropriate
action. For example, if someone is threatening to harm your children, anger
is an adaptive emotional response because it helps you take assertive (or, if
necessary, aggressive) action to end the threat. Fear is the adaptive emotional
response to danger; it prepares one to take action to avoid or reduce the
danger by freezing and monitoring or, if necessary, by fleeing. Therapists help
clients become aware of and act on these emotions, if desirable.
In contrast, maladaptive primary emotions are also direct reactions to
situations, but they no longer help the person cope constructively with the
situations that elicit them. Rather, they interfere with effective functioning.
These emotional reactions generally involve overlearned responses based on
previous, often traumatic, experiences. These are further discussed in the
View of Dysfunction section; however, therapists help clients identify these
and transform them.

Secondary reactive emotions are those that follow some more primary
response. Often, people have emotional reactions to their initial primary
adaptive emotions and replace them with a secondary emotion. This “reac-
tion to the reaction” obscures or transforms the original emotion, leading to
actions that are not entirely appropriate to the current situation. For example,
a man who encounters rejection and begins to feel sad or afraid may become
either angry at the rejection (externally focused) or angry with himself for
being afraid (self-focused), even when the angry behavior is not functional or
adaptive. Therapists validate such emotions, but the goal is to bypass or get
underneath them to the more primary emotion.
Instrumental emotions are those expressed to influence or control others.
They may be deliberate or out of awareness and habitual. For example, croco-
dile tears may be expressed to elicit support, whereas anger may be intended to
dominate; shame is often expressed deliberately to indicate that one is socially
appropriate. Therapists help clients become aware of these emotions and the
aims behind them.
VIEW OF DYSFUNCTION
In EFT theory, dysfunction is not viewed as stemming from any one

mechanism alone. EFT has incorporated into its view of dysfunction such
earlier theories as Rogers’s (1957, 1959) incongruence theory, Gendlin’s
(1982) view of blocked process, the Gestalt notions of unfinished business
(Perls et al., 1951), and existential theory’s loss of meaning (Frankl, 1959).
All these theories have been interpreted in strongly constructivist, phenom-
enologically based terms. The therapist attempts to work with a person’s cur-
rent experience to identify underlying determinants and maintainers of each
person’s problem. Dysfunction is thought to arise via four broadly defined
possible routes, all emotionally based. One or more of these often becomes
the focus of treatment (Greenberg, 2010; Greenberg & Watson, 1998).
The first general source of dysfunction is the inability to symbolize bodily
felt experience in awareness. This might be due to a nonacceptance of emo-
tion, a skill deficit, denial, or avoidance. A second major source of dysfunction
is maladaptive emotions. Although such emotions may be attributed in part
to biological causes, they are most often learned in interpersonal situations in
which an innate emotional reaction such as anger or shame at violation, fear
at threat, or sadness at loss, once useful in coping with a maladaptive situa-
tion, is no longer the source of adaptive coping in the present. For example, in
childhood abuse, the primary source of safety and comfort is both dangerous
and humiliating. The inability to be protected or soothed by the caretaker
thus results in unbearable states of anxiety and aloneness. If early experience

of emotion is repeatedly met with less optimal, or problematic, responses from
caregivers, it will result in the development of core maladaptive emotion
schemes.
A third source of dysfunction in EFT is the inability to regulate one’s
emotions. This involves having too much emotion, as well as having too little
emotion. Problems in emotion regulation can thus result in people being over-
whelmed by strong painful emotion or, alternatively, becoming numb and dis-
tant from their emotions. Finally, a fourth general source of dysfunction stems
from people’s ways of making sense of their experience and their narrative
accounts of self–other and the world. Clients sometimes come to therapy with
problems of meaning and existence. People need help in integrating impor-
tant life stories in the service of forming adaptive identities and establishing a
differentiated, coherent view of self.
EVOLUTION IN VIEW OF DYSFUNCTION
EFT has thus shifted away from its traditional client-centered roots that
conceived of congruence between self-concept and experiencing as the main
mechanism of dysfunction. It has adopted a principle of coherence to replace
it. In this view, problems are seen as arising from the way experience is con-
structed rather than solely from the nonacceptance of experience. They are
also seen as arising from the dysregulation of emotions (being overwhelmed
by them), as well as from maladaptive emotional responding based on pain-
ful feelings (such as fear and shame) derived from past experience. Adaptive
functioning involves both discovery of experience and coordination of differ-
ent aspects of experience. Synthesizing these different aspects of experience
generates a coherent whole that makes conscious sense and forms part of
one’s self-identity. People thus are seen not as possessing a self-concept but
rather as constructing a coherent view of themselves. Through the change
process, in a given moment, people can reorganize themselves from being
afraid and timid to becoming strong and enabled. The manner in which one
constructs oneself in a particular therapy session can then be carried over
outside the session.
STRUCTURE OF EMOTION-FOCUSED THERAPY
In the context of a strong therapeutic relationship that offers the key

client-centered relational conditions and a strong alliance, emotion-focused
therapists offer a particular style of responding from moment-to-moment emo-
tional processing. Various types of empathic and experiential microresponses

form the fabric of therapeutic listening. In-session markers will then arise that
indicate the use of particular emotional processing tasks designed to address a
variety of problems. For a detailed description of how therapy is conducted,
including the provision of various microresponses, recognition of markers,
and implementation of tasks, please see Elliott, Watson, et al. (2004).
RESEARCH ON EMOTION-FOCUSED THERAPY UNTIL 2000
As reviewed by Elliott (2002a), before 2000, the outcome of individual

EFT (then referred to in the literature as process–experiential) was the subject
of at least 11 separate studies with various clinical populations, people with
depression being the most common. Sample sizes in the studies ranged between
six and 22, and posttreatment effect sizes ranged between 0.50 and 2.49, thus
generally demonstrating moderate to large effect sizes. When follow-up stud-
ies were conducted (in five of 11 studies) 4 to 18 months posttreatment, gains
were not only maintained but improved. Two studies showed positive effects
of short-term process–experiential (12–20 sessions) treatment for depres-
sion (Elliott, 2002a; Greenberg & Watson, 1998). The outcome of process–
experiential therapy was also investigated with clients who had experienced
childhood abuse or unresolved relationships with significant others (Paivio &
Greenberg, 1995).
In terms of the study of the relationship between process and outcome,
little research had been conducted before 2000. The handful of studies that
existed had investigated client engagement in therapy as well as client sub-
jective reports of helpful and hindering events (Elliott, 2002a). A number
of research studies were conducted before 2000 that helped clarify the core
EFT client and therapist processes and establish models of the therapeutic
tasks. Studies that also helped identify the essential components of the
models that predicted resolution of the tasks included those conducted on
the two-chair dialogue for conflict splits (Greenberg, 1984), the empty chair
for unfinished business (Greenberg & Foerster, 1996), systematic evocative
unfolding for problematic reactions (Rice & Saperia,1984), meaning cre-
ation work (Clarke, 1989), and focusing (Clark, 1990). Thus, in large part,
early research studies helped define and specify fundamental components of
the treatment. In addition, research began to focus on the effectiveness of
the approach. The York I (Greenberg & Watson, 1998) study showed both
EFT and person-centered therapy to be effective in the treatment of depres-
sion, although EFT was superior in alleviating interpersonal problems and
increasing self-esteem. This was the first study establishing the empirical
legitimacy of EFT.

RESEARCH ON EMOTION-FOCUSED THERAPY SINCE 2000
EFT was getting its start in the later part of the last century, and it began
to grow more significantly after 2000 as research began to proliferate. This
included quantitative, qualitative, and mixed-methods research and an investi-
gation of both the effect of treatment on various disorders, as well as careful
study of the change process.
Quantitative Research on Emotion-Focused Therapy

for Specific Client Problems
On the basis of studies conducted in the past decade, support for the
effectiveness of EFT has been solidified. It is now recognized by the American
Psychological Association Division 12 Task Force as an empirically supported
treatment for depression.
In the past decade, a manualized form of EFT for depression (Goldman,
Greenberg, & Angus, 2006; Greenberg & Watson, 2005; Watson, Gordon,
Stermac, Kalogerakos, & Steckley, 2003) was found to be equally or more
effective than a client-centered empathic treatment or a cognitive–behavioral
treatment (CBT). In a study comparing EFT with CBT (Watson et al.,
2003), both treatments were found to be effective, although EFT was more
effective in reducing interpersonal problems. Small to large pre–post effect
sizes (0.30–1.69) were obtained, considering the sample size in each group
(n = 33) across all measures. Effect sizes for differences between groups at
posttreatment on the Beck Depression Inventory (Beck, Steer, & Garbin,
1988) and the global symptom index of SCL-90-R (Derogatis, 1983) were
very small (0.14 and 0.05, respectively), and differences between effect
sizes on the Self-Esteem Scale (Rosenberg, 1965) and the Dysfunctional
Attitudes Scale (Weissman & Beck, 1978) were somewhat larger (0.30 and
0.34, respectively), suggesting that investigation with larger sample sizes
may be worthwhile.
In the York II depression study, Goldman et al. (2006) replicated the
York I study that was reviewed in Elliott (2002a). The replication study com-
pared the effects of client-centered therapy and EFT on 38 clients with major
depressive disorder. The client-centered treatment emphasized the establish-
ment and maintenance of the client-centered relationship conditions and
empathic responding that are viewed as a central component of EFT. The
EFT treatment added to the client-centered treatment the use of specific
tasks, in particular, systematic evocative unfolding, focusing, two-chair, and
empty-chair dialogue. The York II study obtained a comparative effect size of
0.71 in favor of EFT therapy. The York I and II samples were then combined

to increase the power to detect differences between treatment groups, par-
ticularly at follow-up. Statistically significant differences among treatments
were found on all indices of change for the combined sample (Goldman et al.,
2006). Moderate to large pretreatment–posttreatment effect sizes (0.70–2.86)
for sample sizes (n = 36 in each group) were obtained across all outcome indi-
ces, with those for the depression and symptom change measures being some-
what larger than those for the interpersonal change and self-esteem measure.
Differences were maintained at 6- and 18-month follow-ups. More specifically,
results showed that, at the 18-month follow-up, the EFT group was doing dis-
tinctly better than the P-C group (Ellison, Greenberg, Goldman, & Angus,
2009). Survival curves showed that 70% of EFT clients lasted longer without
relapsing, in comparison with a 40% survival rate for those who were in the
relationship-alone treatment.
EFT for individuals has also been shown to be efficacious for unresolved
relationship issues, including emotional injuries (Greenberg, Warwar, &
Malcolm, 2008; Souliere, 1995) such as unresolved abuse survivor issues
(Paivio, Hall, Holowaty, Jellis, & Tran, 2001; Paivio, Jarry, Chagigiorgis, Hall,
& Ralston, 2010; Paivio & Pascual-Leone, 2010). Building on research and
findings that demonstrate the effectiveness of empty-chair work for helping
clients resolve trauma-related issues (Paivio & Greenberg, 1995), Paivio and
Nieuwenhuis (2001) found that 32 adult survivors of childhood abuse who
received 20 weeks of EFT for trauma achieved significant improvement on
multiple domains of disturbance, compared with waiting-list controls who also
significantly benefited from EFT on receiving treatment. Effect sizes ranged
from 1.03 to 5.71, which are considered large.
A more recent study conducted by Paivio et al. (2010) compared EFT for
trauma that used empty-chair work or what was termed imaginal confrontation
of perpetrators (n = 20) with EFT for trauma that did not use imaginal con-
frontation but instead used empathic exploration of trauma material (n = 25).
Results indicated statistically and clinically significant improvements on eight
measures at posttest, maintenance of gains at follow-up, and no statistically
significant differences between conditions. There were, however, higher rates
of clinically significant change in imaginal confrontation and a lower attrition
rate for empathic exploration (7% vs. 20%).
Recent developments have been made in EFT treatment of anxiety
disorders. Elliott (2013) reported strong initial results from a study conducted
with colleagues, comparing person-centered therapy with EFT and with pub-
lished CBT outcome benchmarks for the treatment of social phobia. Both
person-centered therapy and EFT have been shown to be effective, although
EFT is stronger comparatively (Elliott, 2012; Elliott, Rodgers, & Stephen,
2014). As of yet, empirical studies testing the effects of EFT for generalized
anxiety disorder are still in progress.

EFT in a group format has been shown to be promising for the treatment
of men with a history of intimate partner violence. In a 3-year follow-up inves-
tigating the effects of Relating Without Violence, an emotion-focused group
psychotherapy program, Pascual-Leone, Bierman, Arnold, and Stasiak (2011)
compared a sample of 66 men who completed the treatment with 184 men
from the same prison. At 7 and 8 months postrelease, the treatment group
recidivated by assault, sexual assault, or both significantly less than controls.
Quantitative Process–Outcome Research in Emotion-Focused Therapy
Research support establishing the effectiveness of EFT for a variety of

disorders has grown tremendously in the past decade, and research on the
process of change in EFT has mushroomed. For example, the latter process
has had more research conducted on it than any other treatment approach
(Elliott, Greenberg, & Lietaer, 2004). Research conducted in the past decade
has focused on investigation of the basic emotional change hypotheses of
EFT, along with the relationships among the alliance, the relational condi-
tions, therapist intervention, emotional experiencing, emotional arousal,
and outcome.
The Working Alliance, the Therapeutic Relationship, and Outcome
In EFT, both the therapeutic relationship (Rogers, 1957) and the work-
ing alliance (Horvath & Greenberg, 1989) are strongly emphasized, although
they are considered conceptually distinct. Beyond theory, EFT researchers
have also gone to some trouble to empirically distinguish the three compo-
nents of tasks, bonds, and goals. Studies have shown impressive links among
outcome, therapist empathy, and the working alliance (Elliott, Greenberg,
Watson, Timulak, & Freire, 2013; Horvath, Del Re, Flückiger, & Symonds,
2011; Lambert, 2005). In an attempt to distinguish the two constructs,
Watson and Geller (2005) examined relationships among clients’ ratings on
the Barrett-Lennard Relationship Inventory (Barrett-Lennard, 1962), a mea-
sure of perceived empathy, psychotherapy outcome, and the working alliance
in CBT and EFT. Overall, client reports of therapist positive regard, uncon-
ditionality, empathy, and congruence on the Barrett-Lennard Relationship
Inventory correlated .72 with clients’ self-reports of the working alliance,
pointing to the possibility of conceptual overlap. Nevertheless, client ratings
of the four relationship conditions were predictive of treatment outcome on
a wide range of outcome measures. The impact of the relationship condi-
tions on outcome was mediated by therapeutic alliance for three of four out-
come measures. Researchers thus concluded that the relationship conditions
appeared to be instrumental in facilitating the formation of the therapeutic

alliance, or the therapeutic bond, as well as agreement on goals and tasks.
There were no significant differences on client ratings between CBT and
EFT therapists on therapist empathy, unconditionality, and congruence, but
clients in EFT reported feeling more highly regarded by their therapists than
did clients in CBT. Subsequently, Watson and McMullen (2005) examined
differences between therapist and client behaviors in high- and low-alliance
sessions in EFT and CBT, finding that, in contrast to EFT therapists, CBT
therapists taught more and asked more directive questions, whereas EFT
therapists offered more support.
Modeling Emotional Processing
Pascual-Leone and Greenberg (2007) undertook a state-of-the-art, task-

analytic approach in an effort to map out the actual process by which clients
move through and resolve problematic emotional processing across EFT. In
this model, clients often enter therapy with strong or partially blocked but
undifferentiated feelings (i.e., feeling upset or bad). Global distress is defined
as an unprocessed emotion with high arousal and low meaningfulness. The
model predicts that, in processing their emotions, clients move from a state
of global distress through fear, shame, and aggressive anger to the articulation
of needs and negative self-evaluations; then they move on to assertive anger,
self-soothing, hurt, and grief, states that indicate more advanced processing
(Pascual-Leone & Greenberg, 2007). The model was tested using a sample of
34 clients. Results showed that the model of emotional processing predicted
in-session outcomes and that distinct emotions emerged moment by moment
in predicted sequential patterns.
Depth of Experiencing, the Alliance, and Outcome
Depth of experiencing in therapy has most often been measured by the

Experiencing Scale, a measure constructed originally by Klein et al. (1969)
to test out Rogers’s (1961) original process view that a progressively deeper
internal emotional focus in which clients reflect on their experience to cre-
ate new meaning and resolve their problems in a personally meaningful way
would lead to positive change in therapy. Goldman, Greenberg, and Pos
(2005) set out to study the relationship between the Experiencing Scale and
outcome in both person-centered therapy and EFT with depressed clients.
Recognizing that previous investigations of the same question had used
methods that involved measuring experiencing at the beginning, middle, and
end phases of therapy but with the random selection of segments, Goldman
et al. (2005) adopted an innovative methodology. Influenced by Rice and
Greenberg’s (1984) events paradigm, the study measured experiencing at the

beginning and in three different theme-related sessions across the last half of
therapy. The study found that an increase in client scores on the Experiencing
Scale from early to late in therapy was indeed predictive of outcome and that
it was a stronger predictor than the working alliance. Watson and Bedard
(2006) also found that, in both EFT and CBT for depression, good-outcome
clients began, continued, and ended therapy at higher modal and peak expe-
riencing levels during the session than did poor-outcome clients. Studies
have also suggested that processing one’s bodily felt experience and deepen-
ing this in therapy may be a core ingredient of change, in EFT as well as in
other forms of treatment.
Pos, Greenberg, and Warwar (2009) measured emotional processing
and the alliance across three phases of therapy (beginning, working, and
termination) for 74 clients who had received EFT for depression. Both the
therapeutic alliance and emotional processing significantly increased across
therapy.
Watson, McMullen, Prosser, and Bedard (2011) examined relationships
among client affect regulation, in-session emotional processing, working alli-
ance, and outcome in 66 clients who received either CBT or EFT for depres-
sion. They found that the client’s initial level of affect regulation—that is,
the ability to label, modulate arousal and expression, and reflect and accept
emotion—predicted a client’s ability to differentiate, work through, and pro-
cess emotion during early and working phases of therapy. Findings from these
studies have shown that the quality of the therapeutic alliance is an impor-
tant variable that strongly interacts with the depth and quality of emotional
processing and relates to positive change in EFT.
Emotional Arousal, Productive Emotional Processing, and Outcome
One of the major questions intriguing EFT researchers is the question

of whether emotional arousal is indeed correlated with outcome. More spe-
cifically, researchers have queried whether emotional arousal alone predicts
outcome and, if not, what additional ingredients are important. An examina-
tion of a number of studies reveals a complex picture.
Process–outcome research on EFT for depression has shown that higher
emotional arousal at midtreatment, coupled with reflection on the aroused
emotion (Warwar, 2003), predicted good treatment outcomes. Another study
found that high emotional arousal plus high reflection on aroused emotion
distinguished good and poor outcome cases, indicating the importance of com-
bining arousal and meaning construction (Missirlian, Toukmanian, Warwar, &
Greenberg, 2005). Emotional arousal during imagined contact with a signifi-
cant other was also found to be an important process factor that distinguished
EFT for complex trauma from a psychoeducational treatment and was shown

to relate to outcome (Greenberg & Malcolm, 2002; Greenberg et al., 2008;
Paivio & Greenberg, 1995).
Boritz, Angus, Monette, Hollis-Walker, and Warwar (2011) investigated
the relationship of expressed emotional arousal and specific autobiographical
memory in the context of EFT for depression. Studies established that there
was a significant increase in the specificity of autobiographical memories from
early- to late-phase therapy sessions and that treatment outcome was pre-
dicted by a combination of high narrative specificity and expressed arousal in
late-phase sessions. However, neither expressed emotional arousal nor nar-
rative specificity alone was associated with complete recovery at treatment
termination. Specifically, Boritz et al. (2011) found that recovered clients
were significantly more able to express their feelings emotionally in the con-
text of telling specific autobiographical memory narratives than clients who
remained depressed at treatment termination. Thus, once again, it is aroused
emotion in the context of storytelling that is important in therapy rather
than pure emotional arousal alone as in a catharsis that predicts outcome.
In a study on the relationships among the alliance, the frequency of
aroused emotional expression, and outcome in EFT for depression, Carryer
and Greenberg (2010) showed that a frequency of 25% of moderately to
highly aroused emotional expression best predicted outcome, with signifi-
cant deviations in either direction associated with poorer outcomes. Thus,
some expression of emotional arousal that reflects an inability to express full
arousal, or possibly the interruption of arousal, appears undesirable, rather
than a lesser but still desirable goal.
Another study was able to make further discriminations between produc-
tive and unproductive emotional processing (Greenberg, Auszra, & Herrmann,
2007). Emotional productivity was defined as a person being contactfully aware
of a presently activated emotion, where contactfully aware was defined as involv-
ing the following six necessary features: attending, symbolization, congruence,
acceptance, agency, and regulation and differentiation. These features repre-
sent the ability to reflect on and generate meaning from emotion. Greenberg
et al. (2007) then intensively examined four poor- and four good-outcome
cases, looking at both emotional arousal and productivity. They did not find a
significant relationship between frequency of higher levels of expressed emo-
tional arousal measured over the whole course of treatment and outcome.
Results showed, however, that the productivity of aroused emotional expres-
sion was more important to therapeutic outcome than arousal alone.
The measure of productive emotional arousal used in the Greenberg
et al. (2007) study was further developed and its predictive validity tested on
a sample of 74 clients from the York depression studies (Auszra & Greenberg,
2008). Emotional productivity was found to increase from the beginning to
the working and termination phases of treatment. Working-phase emotional

productivity was found to predict 66% of treatment outcome, over and
above any variance accounted for by beginning-phase emotional productiv-
ity, Session 4 working alliance, and high expressed emotional arousal in the
working phase.
Studies have pointed to the importance of activating emotion in ther-
apy, but at an optimal level: not too little and not too much. Studies have also
suggested that emotional arousal that is expressed in relation to productive
emotion is ideal for promoting success in experientially based therapy.
Therapist Intervention, Client Emotional Processing, and Outcome
Although the majority of process–outcome studies on EFT have inves-

tigated the nature of client processing and outcome, some studies have asked
what the therapist does or does not do to promote deeper and productive
emotional processing. Adams and Greenberg (1996) tracked moment-by-
moment client–therapist interactions, finding that therapist statements that
were high in experiencing influenced client experiencing and that depth of
therapist experiential focus predicted outcome. More specifically, if the cli-
ent was externally focused and the therapist made an intervention that was
targeted toward internal experience, the client was 8 times more likely to
move to a deeper level of experiencing. Given that client experiencing pre-
dicts outcome and that therapist depth of experiential focus influences client
experiencing and predicted outcome, a path to outcome was established sug-
gesting that therapists’ depth of experiential focus influences clients’ depth
of experiencing, which relates to outcome.
A study of EFT for trauma found that therapist competence in facilitat-
ing imaginal confrontation, using empty-chair work, predicted better client
processing. Moreover, when adult survivors of childhood abuse engaged in
empty-chair work, it contributed to the reduction of interpersonal problems,
independent of therapeutic alliance (Paivio, Holowaty, & Hall, 2004).
Research on Therapeutic Tasks
Recent research conducted on therapeutic tasks in EFT has sought to

identify further the key components of resolution and more fully elaborate
some of the less developed tasks that EFT therapists have clinically observed
themselves making good use of, particularly with specific client populations.
Studies on the empty-chair task for unfinished business have shown that
full resolution requires restructuring of unmet needs, a shift toward a more
positive view of self, and a more differentiated view of the other. Furthermore,
clients rated by observers as resolving their unfinished business showed sig-
nificantly greater improvements in symptom distress, interpersonal problems,

target complaints, affiliation toward self, and degree of unfinished business
(Greenberg & Malcolm, 2002). Further studies have also shown that EFT
using empty-chair work for resolving unfinished business was found to be more
emotionally arousing than a psychoeducational treatment. Emotional arousal,
however, did not relate directly to outcome in either group. The authors drew
the conclusion that emotional arousal may signal different processes at differ-
ent times (Greenberg et al., 2008). It might have been more useful to measure
emotional productivity in this context.
In more recent studies of the two-chair dialogue, Shahar et al. (2011)
examined the efficacy of the task at times of stress with nine clients who
were judged to be self-critical. The intervention was associated with clients
becoming significantly more compassionate and reassuring toward them-
selves, leading to significant reductions in self-criticism and symptoms of
depression and anxiety. Effect sizes were medium to large, with most clients
exhibiting only low and nonclinical levels of symptoms at the end of therapy
and maintaining these gains over a 6-month follow-up period.
Keating and Goldman (2002) conducted a task analysis to develop fur-
ther and specify the empathic affirmation task when clients present with
markers of vulnerability and shame. The study helped clarify that, when cli-
ents hit rock bottom in exploring their shameful–vulnerable self, they typi-
cally express core fears related to either annihilation or loss of control; when
they come through deeper emotional processing, they typically feel the need
to reconnect with the therapist and express appreciation to him or her for
being with them and witnessing the painful moments. This task has been
understood to be a less-active EFT task (compared with many that involve
the use of props such as chairs). It is also seen as more interpersonal, in that
the connection with the therapist is strongly emphasized.
A more recent analysis has been conducted on the self-soothing task that
is offered when the client experiences stuck or dysregulated anguish, typically
in the face of a need (e.g., for love or validation) that has been unmet by others.
The necessary steps involve evoking an imaginary child and a soothing other
(usually represented by an idealized parental figure) and helping people soothe
until they feel stronger and internally calmed (Goldman & Fox, 2012).
Qualitative Research in Emotion-Focused Therapy
Advances have been made in both qualitative process and outcome

research on EFT in the past decade. Recently, Timulak and Creaner (2010)
conducted the first-ever qualitative meta-analysis of humanistic and expe-
riential therapies in which a high proportion of EFT studies were reviewed.
Qualitative process studies on EFT have helped clarify the nature of
the key processes in EFT per clients’ subjective reports (in their own words).

Studies have been conducted on client general in-session experiences and
client retrospective reports of helpful and hindering events. In addition, sev-
eral intensive case studies of EFT have been conducted, mostly using Elliott’s
(2002b) hermeneutic single-case efficacy design, which collects a mixture of
quantitative and qualitative process and outcome data from several sources
and also offers a qualitative analysis of causal links between the therapy out-
come and therapeutic processes. By means of this analysis, Stephen, Elliott,
and Macleod (2011) captured the connections between the improvement of
a client with social phobia and her participation in person-centered therapy,
and Elliott (2002b) reported on the change processes in EFT for a client
diagnosed with bipolar disorder. A different analysis reported results of an
adjudicated study of a client with panic and phobia (Elliott et al., 2009).
These studies identified, for instance, the importance of clients’ experience of
connection with the other, increase in awareness of their own needs, support
offered, and credit attributed to the therapist.
Several studies (Honos-Webb, Stiles, Greenberg, & Goldman, 1998;
Honos-Webb, Surko, Stiles, & Greenberg, 1999) have analyzed EFT cases
using the Assimilation of Problematic Experiences protocol that tracks
change in previously warded-off emotion (Stiles, 2002) and the innovative
moment coding system framework (Gonçalves, Mendes, Ribeiro, Angus,
& Greenberg, 2010) that tracks novel moments in therapy signaling clients’
reconceptualization of a problematic self-narrative. Interestingly, in separate
studies, one of the successful EFT cases was analyzed by both systems, each
using different conceptual frameworks. Results from the two studies con-
verged, however, with both reporting that the client’s protest moments, in
which she reclaimed her needs, allowed her to create a distance from signifi-
cant others by whom she felt let down.
The case of Brad explicates how research has been applied to practice
and further illustrates how EFT is conducted. Brad is a semiretired 64-year-old
professor, married for a second time, with five children. One of the children
is from his current marriage, two are stepchildren in his current marriage,
and two are children from a previous marriage. He wants to address his worry
about his health and his future, along with his depression over his perceived
lack of accomplishment. He also feels unloved in his marriage. He was not
able to make his first marriage work and sees his current marriage crumbling.
He is unhappy and lonely and considers leaving on a regular basis. He and his
wife have tried couples therapy and found it somewhat helpful, but she lost
interest in the process. He feels he has failed in matters of love.

Brad had a heart attack a few years ago and now tends to fatigue easily.
His anxiety existed before the heart attack, but he now reports worrying
more. He takes sleeping pills, but only when he really needs to sleep. In
spite of a successful career as a professor, accompanied by much recogni-
tion and many accolades, a position at a prestigious university, and large
research grants, he looks around and feels that his colleagues do not respect
him. He evaluates that he has accomplished little. He feels he has failed
in many respects: career, marriage, and children. Brad shows high levels
of worrying about his health or other people, especially his children. He
anguishes over his relationship with his adult children, all of whom either
have left home and have their own families or are preparing to move out
of the house.
He recalls his mother as being sick much of the time when he was
younger and, therefore, unavailable. His father was physically abusive and
uncaring. He would take Brad to the basement to discipline him with a belt
when he was angry with him. This left Brad with a basic sense of insecu-
rity and attachment anxiety. The client identifies feelings of emptiness and
aloneness.
Much of the early therapy sessions focused on Brad’s heart attack and
its effects. The therapist feels compassionate toward the client but also real-
izes that she is not deeply moved as he talks. In the course of the dialogue, he
does not reveal deep pain, but rather tends to talk in external terms about his
emotions and experiences as if they were not his, or attempts to engage the
therapist in intellectual discussions about topics such as love and the mean-
ing of life. He also spends a great deal of time questioning the therapeutic pro-
cess, wondering whether experiencing his pain will really change it. When
the therapist responds with various empathic reflections, explorations, and
conjectures, Brad focuses internally on his experience but quickly switches to
storytelling that he clearly sees as relevant because it exemplifies his feelings
or talks about a related movie or book. The story, however, tends to move
the dialogue away from his experience. After some sessions, the therapist
begins to make a more concerted effort to focus him on his underlying emo-
tion without being continuously distracted by his interesting but emotionally
barren stories.
By about the fifth session, the therapist, aware of the basic hypothesis
of EFT that high emotional arousal in conjunction with meaning-making
leads to stronger outcome (Missirlian et al., 2005; Warwar & Greenberg, 2000),
is formulating that more productive, optimal emotional processing (Carryer
& Greenberg, 2010; Greenberg, Auszra, & Hermann, 2007; Greenberg &
Goldman, 2007) needs to occur. The client is talking about a recent fight
with his wife. They were spending Thanksgiving without her children,
who were with her ex-husband. As a result, she expresses regret about

leaving her first husband. The therapist attempts to reflect his feeling
about the situation.
Client: So we are getting ready for Thanksgiving dinner and she
seemed kind of down and sad, so I said, “I am sorry your kids
could not be here with you.” She says, “I have been thinking
about that. I think divorce should be illegal.” Well, that was
it. That comment just killed the dinner. For the meal, we sat
together in silence and tension for 2 hours.
Therapist: It felt like such a slight.
Client: Yeah, as usual, there is just no communication between the
two of us. Did I tell you what her ex-husband did the other
day?
Noticing that the client is going to change the subject, and having gone
down this road before, the therapist does not want the story to serve as a
distraction. She sees a risk of losing an important opportunity to focus on his
underlying feelings. Indeed, research has shown that, in response to a thera-
pist response targeted toward internal experience, a client is significantly
more likely to focus on internal experience (Adams & Greenberg, 1996).
The therapist, therefore, brought the focus back to his feelings, saying, “And
you were hurt.” The client agreed: “Yes,” he said. Knowing how difficult
it was in that moment for the client to focus on his feelings, the therapist
initiated a mini-focusing task. “Can we try something?” the therapist asked.
“Sure,” the client agreed. The client and therapist had a strong alliance, and
research has shown that the therapist is much more likely to succeed if client
and therapist agree on the tasks and goals of therapy (Watson & McMullen,
2005). In this case, the bond was strong, and the client was open to the
therapist’s suggestion. The therapist initiated a focusing exercise (Elliott,
Watson, et al., 2004; Gendlin, 1982):
Therapist: So, if we go back and kind of remember the fight you had
and that horrible tension as you sat in silence at the Thanks-
giving dinner, can you kind of take a moment and breathe,
and maybe focus inside your body, perhaps on your stomach?
Close your eyes if you need to.
The client closed his eyes and put his hand on his stomach.
Therapist: So I see you putting your hand on your stomach–that is good.
So if you sort of focus inside there and remember what you
were feeling . . . what is the sensation or feeling that you had
in your stomach as you sat there?
Client: Well, it was kind of a tight feeling, and a sort of sinking
feeling.

Therapist: Yes, sort of a sinking feeling, almost heavy . . . ?
Client: Yeah, very heavy, very sad. I guess I felt kind of down, sort of
rejected.
Therapist: Yeah, right, sort of rejected and hurt, so if you can just stay
with that feeling a little and kind of let it be there, let it have
a voice. . . .
Client: Yeah, it is just so sad, it’s like I am at the bottom of a dark
well and I am screaming out and no one can hear me.
Therapist: Yeah, it is like you are crying, so sad, and you just want them
to hear but no one does.
Client: Yeah, that is right, but they don’t listen.
Therapist: That is right, it is like I really need you to come to hear me.
Client: Yeah, I do.
It seems the client is benefiting from a more purposeful and direct exploration
of his bodily-felt experiencing (Goldman et al., 2005).
In a later session, the client talks about how sure he is that none of his
colleagues respect him and that even his wife, who is supposed to love him,
does not hold him in high esteem. He is feeling quite depressed and does not
think the situation is likely to ever change. The therapist thus hears a marker
for a two-chair conflict split and formulates (Goldman & Greenberg, 1997,
2015) that it would be best to initiate a two-chair dialogue. They begin work-
ing with the split as an attributional split, where the client is asked to enact
the other or the external situation wherein his colleagues and even his wife
are in one chair, embodying the critical aspect of himself.
Client: [Critic, played by colleagues] You are just worthless, you’re a
lecherous old man. You have nothing to offer. You should
be ashamed of yourself. You think you have accomplished
something important but, in fact, you have not. You have
nothing to show for yourself, and you should just stop try-
ing because you are never going to prove that you are worth
anything. Do you think it is important that you have grants?
Nobody thinks so. You are a fool because everyone knows
you’ve not really made any significant contribution and it
will always be like this.
Therapist: OK, now can you come over here [pointing to self-chair.
Client moves]. So what is it like over here, what does it feel
like when he talks to you like that?
Client: Well, it hurts. I don’t like it. But I think it is true. That is
what they really think of me.

Therapist: It hurts. Can you tell them that? Tell them what it is like
for you.
Client: Well, it hurts when you talk to me like that. Because I think
it is true. I feel scared, because I think you might be right.
Therapist: Tell him what it feels like. I am scared. What do you feel like
inside right now?
Client: I feel very small, very small indeed. You know, it is funny, but
I do experience it in life that they feel that way about me, and
even my wife, but right now, it seems to me that it is me sitting
over there. Like the critical, disapproving part of me.
Therapist: Yes, right, well, I guess in a sense you are your worst critic.
And you do imagine them saying these things and think-
ing them. But really, it is the things that you imagine they
say that sort of echo these negative things you think about
yourself. Can we get a sense of how you do this, what you say
to yourself? Making him feel like he is small, unimportant,
worthless . . . how do you make him feel that way?
Client: Well [coming back to critic chair], you are just a nothing, you
are a little pea. You are miniscule. You amount to nothing.
Therapist: Yes, what does that feel like? What do you feel when he talks
to you like that?
Client: I feel small, like a nothing. [Makes his hands into the shape of
a little pea.] That is how I feel.
Therapist: Yeah and it hurts. Right, tell him. Tell him, I feel small. Tell
him what you need from him.
Client: I need him to give me some space. I need him to see me. To
see that I deserve a voice.
Therapist: It is like I need him to believe in me. Right, tell him. I need
to be seen. I need a voice.
Client: Yeah, that is right. I do. I need you to see me. I need you to
know that I am important.
Therapist: Yeah, I am important, and I need you to see that. How does
that feel to say that?
Client: [Taking a breath out] It feels much better. I feel like I can
breathe.
There are several important moments in this dialogue. One important
aspect of the chair dialogue, in particular with anxious splits, is getting at how
the critic plays a catastrophizing role, projecting fear, doom, and gloom into

the future. This client is making himself feel he is incompetent and hope-
less and always will be. The client comes to realize that it is not, in fact, his
coworkers who are the source of his pain, but rather that he himself is very
critical and that makes him feel ashamed. The therapist helps him access the
underlying feelings and his need to feel important. The critic makes him feel
he is not worthwhile and is therefore unlovable.
Part of case formulation in EFT (Goldman & Greenberg, 2015) involves
the coconstruction of a narrative that helps tie presenting problems and
underlying emotion schemes to relational and behavioral difficulties. This is
usually done in one of the midstages of the formulation, after a therapeutic
relationship (Watson et al., 2011) has been formed, emotional exploration has
occurred, and tasks have been undertaken, so that, as a result, new emotional
awareness and sometimes transformation have been sought. The client will
naturally attempt to fit new emotions and meanings into existing narrative
structures; this sort of marking and conceptualizing of the client’s problems
in terms of underlying emotional processing difficulties helps to consolidate
changes further and provide a focus for future work. Thus, in the seventh
session, when the client is wondering about his anxiety and what purposes it
serves, the therapist says to the client,
So it seems like your worry is an attempt to protect against your feelings
of anger and sadness, and this basic feeling of aloneness and insecurity.
Your worry is like a sentinel that is on guard against feeling these painful
feelings. If you worry, you can anticipate anything bad before it happens,
and that seems to give you some sense of control. However, then you
can never be relaxed; you are always on guard. What we need to do is
help you deal with your underlying feelings.
“Yes,” the client agrees, “I do think there is a pain that is hard for me to
feel, and maybe there is some deeper sadness.” Together, the client and therapist
are forming an understanding that worry is secondary to more fundamental, pri-
mary emotions such as core anger and sadness. The therapist validates worrying
as distressing but attempts to refocus on primary emotions underneath.
By the eighth session, the client begins to recognize that his worry is
an avoidance of sadness and reports that the sadness is about the state of his
life and opportunities that he has missed. The client has to grieve, in a sense,
what he has lost. The focus changes to his feelings of not being lovable,
because he recognizes that his parents were not capable of giving him the love
he needed, that he felt neglected much of the time, and that he could not
recall anyone ever caring much about him or his well-being. His memory was
of being ignored and, when he displeased his father, being hit. It was difficult
for him to recall positive memories or interactions with either of his parents.
Client and therapist undertake an unfinished business dialogue (Greenberg
& Foerster, 1996; Greenberg et al., 2008) with his mother, in which he first

attempts to express sadness to her. He interrupts it, however, saying such
things as “Don’t bother your mother, she is sick.” In turn, he shuts down and
feels resigned to not being able to get his needs for comfort met. Working
through his resignation and protectiveness helps him to contact his feelings
of aloneness and his need to grieve his loss.
Client: [saying to mother] [crying] I really needed to know you cared.
I needed to know you were there. I needed you to notice
what I was doing.
By the end of the dialogue, the client’s mother has acknowledged and vali-
dated his need, saying, “I am sorry I was not there for you. I know I was sick
and unavailable, but I know you really needed me.” He is able to forgive his
mother and understand that, although she was unavailable, she did love and
care for him.
After a number of sessions on unfinished business with his mother, in
the 14th session, therapist and client work on unfinished business with his
father. In the following dialogue the client expresses his feelings:
Client: [to father in the chair] You never cared about me. You only
ever talked to me when you needed something. You were not
good to us. You were mean to mom and I didn’t like the way
you treated me. You were mean to me.
Therapist: Yes, tell him. I didn’t like the way you treated me. Tell him
what you resent.
Client: Well, I resented you for the way you ignored me most of
the time. The only time you paid any attention was when I
didn’t do as you asked or I was in your way. I resent you for
how mean you were. I—I didn’t like it when you hit me for
no good reason.
Therapist: Yes, tell him. I resented you for hitting me.
Client: Well, yes, I did. I really hated him.
Therapist: Right, tell him. I hate you for what you did to me. I hated
that you hit me.
Client: I hated you. I hated you so much. I just wanted you to—
poof!—go away. You really hurt me. And you shouldn’t have
done that to me. I was just afraid of you. You were mean. You
left me feeling I had no right to exist. And I hate you for that.
Therapist: Right, tell him. I hated you for making me feel afraid.
Client: Yes, you made me feel afraid, when all I wanted was to admire
you.
Therapist: Right, tell him, I needed a father who I could look up to, who
would guide and help me. Not hurt me.

The dialogue continued in this vein for the rest of the session. An impor-
tant outcome was that he was able to stand up to his father and express his
needs for validation. In the next few sessions, the client also accessed sad-
ness and vulnerability over not having a father he could admire and who
could guide him.
Overall, the therapist observed and was guided by the EFT model of
emotional processing (Pascual-Leone & Greenberg, 2007). The therapist
saw an initial presentation of global distress or, in this case, worrying (anxi-
ety), hopelessness, and resignation. Such secondary feelings obscured core
maladaptive feelings of fear of loss and sadness at lonely abandonment that
were expressed as “I feel insecure and unable to cope on my own.” Therapist
and client were eventually able to access the client’s core needs for protec-
tion and security. The change process was one of moving from secondary,
externally focused worry through internally focused anger and sadness and
eventually expressing a need for love. The client was able to say, “I deserved
to be taken care of.” Sadness and grief were expressed at the loss of the
mother and father he wished he had. Eventually, he was able to access self-
soothing and compassion for the lonely child, with one part of the self saying,
“I’ll take care of him.”
Through participation in chair work over the course of therapy, the cli-
ent was able to feel that his needs were legitimate and that he was able to
survive his painful feelings of abandonment. He became able both to soothe
his self and to assert his needs to his wife and children. The therapy involved
completion of the various forms of chairwork that involved the discovery of
new emotions and meaning. In a later phase of therapy that involved the
integration of new meaning and the creation of new narratives, the client told
the therapist about an event with his wife in which he asserted himself. The
therapist reflected, “So somehow you have become more aware of your needs,
and it is okay to express them. So what you want is important and it does mat-
ter, and it is okay to tell her.” The client replied, “Yes, I said what I wanted and
at first she was resistant, but then she said OK, and that was that [grinning].”
CONCLUSION
EFT has grown primarily out of two major humanistic therapy tradi-
tions: client-centered and Gestalt therapies. Evolving from its theoretical
roots, integrating emotion and constructivist theories, EFT has emerged as
a therapy in its own right in the past 30 years. Research has greatly aided
the development and specification of EFT. Outcome research has helped to
establish EFT in the world of evidence-based treatments for specific disorders.
Recent studies have clearly established support for EFT in the treatment of

depression. More recently, EFT has been shown to be effective for the treat-
ment of complex trauma, social phobia, and intimate partner violence. Studies
are currently underway that investigate EFT for generalized anxiety and eating
disorders. In the past decade, process–outcome and mixed-methods-design
research studies have proliferated, helping to establish support for the basic
hypotheses and tenets of EFTs while further elaborating and articulating more
specifically how emotion changes over the course of therapy. Both quantita-
tive and qualitative research as well as case studies have painted a very reveal-
ing and complex picture of the change process in EFT.
It seems that, in the context of a strong, empathic therapeutic alliance,
therapists help clients to work productively through their emotions in relation
to specific narratives and autobiographical memories to coconstruct new emo-
tional processes. Therapists use a variety of emotional processing tasks to help
clients deepen emotional experiencing, attain optimal levels of emotional
arousal, and form new meaning. This is related to a positive client outcome in
therapy. Research studies have been used to help strengthen, largely through
specification, the model of EFT. Findings gleaned through research studies
have, in turn, helped us communicate and write about the therapy in an effort
to train the next generation of emotion-focused therapists.
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IV
Therapeutic Modalities
11
EMPIRICALLY supporTED
HUMANISTIC APPROACHES
TO WORKING WITH COUPLES
AND FAMILIES
CATALINA WOLDARSKY MENESES AND ROBERT F. SCUKA
Humanistic psychology and psychotherapy are characterized by a posi-

tive view of human functioning, a commitment to phenomenology, a belief in
the capacity for self-determination, the promotion of in-therapy experiencing,
and a commitment to a person-centered therapeutic relationship (Greenberg,
Elliott, & Lietaer, 2003). In working with couples and families, the therapist
aims to understand empathically people’s experience within the system in a
nonjudgmental and nonpathologizing manner. According to Gurman (2008),
the therapist does so with the intention of helping individuals enhance their
relationships.
Although there are a variety of humanistic approaches to working with
couples and families, this chapter outlines the new developments in theory
and research relevant to those that are empirically supported. Currently, this
includes relationship enhancement (RE) therapy, emotion-focused couples
therapy (EFT-C), Gottman’s method for couple therapy, filial family therapy
http://dx.doi.org/10.1037/14775-012
S. Rubin (Editors)
353
(FFT), emotion-focused family therapy (EFFT), and dyadic developmental
psychotherapy (DDP).
HISTORICAL AND THEORETICAL OVERVIEW

OF HUMANISTIC COUPLE AND FAMILY THERAPY
In the attempt to understand difficulties in living within families, the

field of family therapy moved from focusing on the behavioral input–output
of the system and its feedback loops to targeting the family’s underlying struc-
ture (hierarchies, triangles, boundaries, etc.) and all of its associated beliefs
(i.e., rules, myths, and secrets) while attending to the context within which
the family is embedded (Rasheed, Rasheed, & Marley, 2010). The emphasis
on understanding interactional patterns generally disregarded the experience
of the individual until Virginia Satir advanced her method of therapy.
Like her contemporaries from Palo Alto, California, Satir believed that
symptoms are functional within a system and that communication is central
in family process. Satir (1972, 1988) proposed that people long to feel good
about themselves and to get close to others, noting that one of the most
important family functions is the enhancement of self-esteem. She further
proposed that self-esteem and communication are intricately connected. As
family members drop their “protective masks” and express their underlying
feelings, honest communication flows, and the system can attend to the needs
of individuals and nurture their personal growth. This promotes self-esteem
(Satir, 1972, 1988). Satir’s approach integrated core humanistic principles
inspired by Rogers and Maslow, along with experiential interventions, for the
purpose of exploring and understanding the in-session emotional experience
of each individual within the system.
Current empirically supported humanistic approaches are guided by an
understanding of the mechanisms of change in therapy and a constant attun-
ement to the system. This has resulted in a process-oriented manner of conduct-
ing therapy, in which specific interventions are introduced at specific moments
based on a client’s particular presentation (rather than on intuition or strict
formulas dictated by a treatment manual) and are offered in the spirit of prizing
each individual’s growth potential (Greenberg, Rice, & Elliott, 1993).
Relationship Enhancement Therapy
Bernard G. Gurney Jr. developed one of the first humanistic therapies

for working with couples: RE therapy (B. G. Guerney, 1977; Scuka, 2005).
The core conviction behind the RE model was that the primary source of
354 meneses and scuka

family distress was a deficit of good relationship skills. Hence, RE extended
Rogers’s emphasis on the use of empathy in therapy by incorporating basic
tenets of learning theory to develop a systematic methodology to teach couples
and families good communication and other relationship skills. Although the
psychoeducational skills teaching component of RE therapy has been stan-
dardized (and is not typical of humanistic approaches), this condition simply
lays the groundwork for the core of the therapeutic work, which allows for
a broadly experiential dialogue process aiming to plumb the depths of the
clients’ emotions and concerns. The dual goal of this experiential process
is to promote self-acceptance and self-understanding as well as a deeper
connection and healing between partners and family members, resulting
in symptom change, personal growth, and new definitions of self and rela-
tionship (B. G. Guerney, 1994).
The skills taught in RE include the following: (a) expressive skills, such
as stating one’s desires assertively, subjectively, and respectfully; (b) empathic
skills that facilitate listening to and understanding others more deeply;
(c) discussion and negotiation skills that follow a structured dialogue pro-
cess; (d) coaching skills to help partners keep their dialogues on track when
mistakes get made; (e) problem-solving skills to devise creative, win–win
solutions; (f) changing self skills to reduce unwanted behaviors; (g) helping
others change skills to support others in implementing their agreements;
(h) conflict management skills to help partners exit from cycles of hostility
and blame; (i) generalization and maintenance skills; and (j) forgiveness
skills to overcome alienation and foster healing (B. G. Guerney & Scuka,
2005, 2010).
The goal of the skills training in RE is to decrease interactions that cre-
ate anxiety and emotional insecurity while increasing participants’ capacity to
show and receive love (B. G. Guerney, 1994). RE fosters the systematic recon-
figuration of interactional patterns, moving away from dysfunctional, alienat-
ing patterns toward nurturing ones. RE also aims to foster problem prevention
by equipping couples and families with the skills to solve future challenges
successfully on their own (Scuka, 2005). There is flexibility in the application
of this approach, as it can be offered in a structured or experiential format,
within the context of a group or with a couple or family. Home assignments
are used to promote integration of RE skills in daily life.
Emotion-Focused Therapy for Couples
In 1988, Greenberg and Johnson developed a therapeutic model that

assimilated the systemic perspectives into an experiential approach that
resulted in a promising way of working with couples. Over time, the authors
began to diverge on their theoretical conceptualization of interpersonal
working with couples and families 355

dynamics, giving rise to two related but slightly different “versions” of the
same approach. Inspired by the work of Bowlby, Johnson’s (1996, 2004)
emotion-focused therapy (EFT) emphasizes attachment as the central force
that organizes couples’ behavior, whereas Greenberg and Goldman’s (2008)
EFT-C emphasizes the role of affect regulation in couples’ dynamics, pro-
viding a framework that integrates the motivational forces of attachment,
identity, and liking/attraction.
According to Johnson (2004), individuals have an innate need to main-
tain closeness to a significant other. When both partners are able to express
their emotions and needs, and simultaneously respond to their partners’ emo-
tions and needs, a secure attachment bond is established. Disruptions to this
bond typically lead to partners engaging in rigid interactional cycles in an
effort to meet attachment needs.
Greenberg and Goldman (2008), on the other hand, consider emo-
tional regulation to be at the core of interpersonal dynamics. In line with
Frijda’s (1986) view of emotions, Greenberg and Goldman considered behav-
ior, motivation, thoughts, and needs to be intimately linked to our emotional
state. They argued that without affect there would be no attachment, as they
considered affect regulation to be a primary human motivation, suggesting
that people bond because of the feelings relationships give them. That is,
partners seek the closeness of a safe-other because it generates an array of pos-
itive feelings. In contrast, they retreat when they feel afraid, or they respond
in anger when they feel attacked or threatened.
Greenberg and Goldman (2008) further proposed that the primary moti-
vating force of affect regulation operates through three primary subsystems:
attachment, identity, and attraction/liking. From this perspective, couples’
conflict is said to result from the painful feelings emanating from unmet adult
needs for attachment (proximity, availability, and responsiveness) and iden-
tity (feeling accepted and validated), and it is ameliorated by positive feelings
of attraction and liking. Whereas Johnson (2004) suggested that a secure
attachment bond provides the necessary conditions to help the partners regu-
late their emotions, Greenberg and Goldman proposed that couples’ conflict
is fueled by emotions related to both attachment and identity needs. As such,
there may be times when a partner’s maladaptive emotion schemes relate
more clearly to unmet childhood needs and/or emotions linked to the dimen-
sion of identity (e.g., shame) that cannot solely be regulated or transformed
through a secure attachment bond or a partner’s soothing but instead require
self-focused work including developing the capacity to self-soothe. Thus, for
Greenberg and Goldman, couples’ conflict is understood as stemming from
rigid, interactional cycles that are activated when there is a breakdown in
self- and other-regulation of affect. The application of self-soothing tech-
niques to address fears and unmet needs that generally stem from experiences

within the family of origin is central for Greenberg and Goldman, in addition
to assisting couples to develop proficiency in meeting each other’s needs and
engaging in other-soothing. Therapy involves exploring and understanding
the functions of primary, secondary, and instrumental emotions, which are
outlined later. The aim is to help each partner become aware of and symbolize
the underlying attachment and identity-oriented emotions (e.g., fear under-
neath the anger/hostility or shame/inadequacy underneath contempt) and to
realize that expressing secondary or instrumental emotions is what keeps him
or her engaged in his or her interactional cycle.
Both Johnson’s (2004) and Greenberg and Goldman’s (2008) versions
of emotion-focused couple work are highly similar in clinical practice, as both
assert that distress occurs when couples relate to each other with constricted
emotional patterns that lock them in rigid interactional dynamics. Therapy
aims to transform problematic dynamics by helping partners explore and
express their underlying primary emotions to create new corrective emotional
experiences of mutual openness, responsiveness, and validation (Greenberg
& Johnson, 1988). Primary emotions refer to an individual’s initial feelings
about a situation (e.g., fear when one feels attacked), whereas secondary emo-
tions refer to reactions or even a defense against primary internal responses or
emotions (e.g., anger in response to feeling hurt). Instrumental emotions are
used to fulfill a wish or need in an indirect way (e.g., crying in an attempt to
seek closeness; Greenberg, Rice, & Elliott, 1993).
Following Greenberg and Johnson’s (1988) original joint research ini-
tiatives, Johnson went on to disseminate and develop the couple therapy
approach, demonstrating its effectiveness for a variety of types of marital dis-
tress. Greenberg, however, focused on advancing the model for individuals,
conducting extensive process research that in many ways inspired the refine-
ments made to the 1988 couple’s model developed with Johnson. Greenberg
returned to conducting process research with couples approximately 10 years
ago, as outlined in the next section. For his commitment to research in psycho
therapy and his founding role in establishing EFT as an evidenced-based
psychological intervention, Greenberg was awarded the Lifetime Distinguished
Researcher Award in 2012 by the American Psychological Association.
Gottman’s Method for Couple Therapy
Gottman’s research has been highly influential in highlighting the power

of emotional expression in couple dynamics. Observations of couple inter
actions, in conjunction with physiological data gathered, informed Gottman’s
(1994) findings regarding the trajectory to marital dissolution (i.e., via criti-
cism, contempt, defensiveness, and stonewalling).

Positive affect is also central to the well-being of couples. Healthy couples
have been observed to display a 5:1 ratio of positive behaviors to negative ones,
even during conflict (Gottman, 1994; Gottman & Levenson, 2002). Positive
affect plays an important role in marital stability among newlyweds (Buehlman,
Gottman, & Katz, 1992) and in long-term couples. Using mathematical mod-
eling, Gottman and Levenson (2002) predicted the timing of divorce with 93%
accuracy: Negativity expressed during conflict early in married life predicted
early divorce, whereas a lack of positive emotions in daily events and during
times of conflict predicted later divorce.
Over time, Gottman’s focus shifted to developing and testing methods
aimed at reversing the cycle of marital distress and enhancing marital satisfac-
tion, which culminated in the sound relationship house theory (Gottman,
1999; Gottman & Gottman, 2008). This approach incorporates an array of
empirically supported interventions, including psychoeducation, systemic-
based interventions, experiential exercises, and behavioral strategies designed
to help couples deepen their friendship, strengthen their conflict management
skills, and develop a shared meaning and purpose in their relationship.
Gottman and Gottman’s (2008) therapy method involves set protocols
and structured exercises to aid couples to develop a deeper perspective into
their relational conflict as well as to enhance skills such as empathic listening,
compassionate validation, self-soothing, acceptance of influence and com-
promise, and repair of emotional wounds. According to Gottman (1999), the
therapist’s role involves empowering, encouraging, supporting, and guiding
the couple. This is in line with the humanistic spirit; however, because the
approach relies heavily on behavioral strategies, further review of Gottman’s
contribution is beyond the scope of this chapter.
Filial Family Therapy
This approach is an adaptation of Rogerian-based child-centered play

therapy (CCPT), first developed by Axline (1947) in her seminal book Play
Therapy. Bernard and Louise Guerney developed FFT by adding a psycho-
educational skills training component to CCPT that would (a) teach parents
the basic CCPT skills—so that they could conduct therapeutically oriented,
nondirective play sessions with their own children—and (b) provide ongoing
supervision to parents to improve their ability to offer empathy and accep-
tance to their children while also learning how to set limits effectively. One
of the original motivations behind the creation of FFT was the conviction
of the value of harnessing natural family relationships in order to promote
family healing (B. Guerney, 1964). FFT enables parents to help their children
with emotional and behavioral problems through understanding and accep-
tance. This allows children to be more understanding and accepting of their

own emotions, which promotes better emotional regulation and, therefore,
improved behavioral self-regulation.
FFT was originally conducted in a group format (B. Guerney, 1964;
L. Guerney & Ryan, 2013) to maximize interpersonal modeling and group
support. It has also been successfully adapted into an individual family
therapy format (VanFleet, 2005). In either format, the therapist–parent
relationship is crucial, as the therapist teaches, models, coaches, and rein-
forces desired parent skills and behaviors. An essential part of the parent’s
learning process is observing the therapist model good relational skills and
later putting these same skills into practice. By experiencing the therapist’s
acceptance of the parent’s emotions, it is believed that the parent will
develop acceptance of the child’s emotions. FFT aims eventually to have
the parent conduct play sessions at home, independent of the therapist,
and to maintain one-on-one “special time” with his or her child once the
sessions are discontinued to continue nurturing the relationship.
The sequence of FFT sessions involves the following: (a) determination
of FFT appropriateness and introduction of the FFT method, including how
to prepare the child for play sessions; (b) parental skills training, including the
therapist role-playing the child to help parents practice the FFT skills; (c) one
or more demonstration play sessions by the therapist with the parents’ child;
(d) parents conducting play sessions with their child, with supervisory feed-
back provided by the therapist; (e) preparing the parents for home sessions;
(f) home sessions (ideally videotaped), with supervisory feedback; (g) general-
ization of the FFT skills to daily home life; and (h) termination.
Emotion-Focused Family Therapy
This approach centers on having family members explore the emotions

that underlie their interactions and express vulnerable, primary emotions and
their associated needs (Johnson & Lee, 2005). EFFT is usually conducted over
10 to 12 sessions with triads or dyads, although the family is seen together
both at the beginning and end of therapy.
The use of EFFT has been particularly fruitful in the field of eating dis
orders, where it has been integrated with traditional family-based therapy.
EFFT aims to address emotional regulation skills while simultaneously introduc-
ing adaptive eating behaviors (Robinson, Dolhanty, & Greenberg, 2015). On
the basis of Greenberg’s (2010) views that emotion is central to the construc-
tion of the self (and its internal organization), and that healthy emotional
processing arises from accurate mirroring and validation from caregivers, the
objective is to have parents become “emotion coaches.” The EFFT thera-
pist views family dynamics in terms of how emotions are experienced and
expressed. Parents learn the skills to teach their child with an eating disorder

to turn to them rather than the symptomatic behavior when emotionally
dysregulated.
Over the three stages of treatment that integrate psychoeducational,
experiential, and systemic strategies, parents learn the basic skills to support
their child in terms of his or her emotional functioning and eating habits.
Parents work through their own emotional vulnerabilities and blocks in indi-
vidual and family sessions to serve as their child’s emotion coach. As parental
empathy skills are enhanced, the focus shifts to having the parents work
through losses and failures that occurred in the family and to take responsi-
bility for their behavior (e.g., “I’m so sorry you had to go through that. That
must have been awful for you. I should have found another way to deal with
my depression”). This invites the child to work through the pain related to
these injuries and his/her sense of blame for the onset and development of
the eating disorder. The final stage of treatment involves supporting the child
with separation and identity formation.
Dyadic Developmental Psychotherapy
Developed by Hughes and colleagues in the 1990s to address the impact

of abuse and neglect in children who had been in foster care or adoptive
homes, DDP has evolved into a comprehensive model of family therapy also
known as attachment focused family therapy (Hughes, 2007). This model
focuses on strengthening the attachment bond between parent and child by
attending to coregulation of emotion and creation of shared meaning, as well
as by the therapist’s use of self in-session and his/her ability to both follow and
guide the family. The child’s behavioral difficulties are understood in the light
of past emotional injuries (EIs) that need to be healed. Research indicates
that DDP can foster more secure attachment bonds and reduce problematic
behaviors (Becker-Weidman & Hughes, 2008).
RESEARCH IN HUMANISTIC COUPLE AND

FAMILY THERAPY PRIOR TO 2000
Early Research in Relationship Enhancement and Filial Family Therapy
The RE model has a strong empirical research base that encompasses

both RE therapy and the RE Educational Program. In a meta-analytic study,
Giblin, Sprenkle, and Sheehan (1985) demonstrated its superiority to 13
other models, including other communication skills training approaches,
behavioral approaches, and religion-based approaches. This study found an
average effect size for RE of 0.96, in comparison with 0.44 across all other
approaches. Superior outcomes were noted for approaches with more structure,

emphasizing skills training and behavioral practice. A second meta-analysis
conducted by Hahlweg and Markman (1988) confirmed the effectiveness of
RE, with an even stronger effect size of 1.14.
RE has been used with various populations and across a range of problem
severity, from primary prevention programs aimed at helping couples change
parenting practices associated with psychopathology to relapse prevention
programs for psychosis (Vogelsong, Guerney, & Guerney, 1983). RE has also
shown superior results compared with a Gestalt approach (Jessee & Guerney,
1981) and strategic marital therapy (Steinweg, 1990). RE has further demon-
strated positive 1-year follow-up results with an increase in gains compared
with a posttest for both mother–daughter dyads (B. G. Guerney, Vogelsong,
& Coufal, 1983) and couples (Griffin & Apostal, 1993). These unexpected
outcomes provide powerful testimony as to the long-term effectiveness of RE
even after therapy has ended.
FFT was developed on the basis of CCPT. A meta-analysis of 93 empiri-
cal research studies on play therapy found FFT to be the most effective form
(Bratton, Ray, Rhine, & Jones, 2005). The group of 26 FFT studies had an
average effect size of 1.05, whereas the subgroup of 22 FFT studies that focused
exclusively on training parents had an average effect size of 1.15. FFT is a pow-
erful family therapy intervention that uses play to enhance child functioning
and parent–child relationships.
Early Phase of Research in Emotion-Focused Therapy for Couples
EFT has a strong research tradition that includes investigation of its

efficacy (e.g., A. Goldman & Greenberg, 1992; Johnson & Greenberg, 1985)
and exploration of the process of change in therapy (Greenberg, Ford, Alden,
& Johnson, 1993; Johnson & Greenberg, 1988). The preliminary efficacy
studies on EFT, which were led by Greenberg and his doctoral students, typically
involved comparisons between EFT and other approaches or between EFT and
a wait-list control. For example, Johnson and Greenberg (1985) found a large
treatment effect when EFT for couples was compared with a wait-list control,
along with superior outcomes on marital adjustment and intimacy when EFT
was compared with standard behavioral couple therapy. For more severely dis-
tressed couples, EFT yielded similar results to a systemic interactional approach
(A. Goldman & Greenberg, 1992), yet had lower rates of relapse.
In the mid-1980s, the first intensive task analyses of couples’ conflict
resolution were conducted (Greenberg & Johnson, 1986; Plysiuk, 1985),
revealing that accessing underlying self-experience and the softening of the
critic—processes central to intrapsychic conflict resolution (Greenberg,
1979)—were also important in interactional conflict resolution. Subsequent
research by Johnson and Greenberg (1988) examined the unique elements of

conflict resolution in couples, revealing that good sessions were characterized
by (a) deeper levels of experiencing, as measured on the Experiencing Scale
(Klein, Mathieu, Gendlin, & Keisler, 1969), and (b) interactions character-
ized as “affiliative” (e.g., disclosing, supporting, and understanding), as coded
by the Structural Analysis of Social Behavior system (Benjamin, 1974).
Indeed, these in-session processes successfully predicted outcome. One study
by Greenberg, Ford, et al. (1993) also found that the behavior of partners was
significantly more supportive, affirming, and understanding in the late phase
of therapy (Session 7) than it was during the beginning phase (Session 2).
Another study (Greenberg, James, & Conry, 1988) found that spouses were
more likely to respond affiliatively to their partners after having witnessed
them engage in vulnerable self-disclosures.
These research findings lend empirical support to the importance of reveal-
ing underlying feelings in couples conflict resolution, which is at the heart of
EFT for couples. A meta-analysis of the four most rigorous EFT studies revealed
a 70%–73% recovery rate for relationship distress (86% significant improve-
ment over controls) and an effect size of 1.3 (Johnson, Hunsley, Greenberg,
& Schindler, 1999). In addition, the long-term benefits of this approach have
been documented (Cloutier, Manion, Walker, & Johnson, 2002). Thus, EFT-C
is considered to be an empirically supported approach (Snyder, Castellani, &
Whisman, 2006).
RECENT DEVELOPMENTS IN EMPIRICALLY SUPPORTED

HUMANISTIC APPROACHES
Relationship Enhancement Since 2000
Accordino and Guerney (2002) conducted the most comprehensive sum-

mary of RE research to date, reviewing 25 studies, each demonstrating the effec-
tiveness of RE in terms of one or more outcome measures. (For a more detailed
analysis of the more important RE research studies, see Scuka, 2005.) Five of
the studies involved a direct comparison of RE with another model, includ-
ing reciprocal reinforcement (Wieman, 1973), traditional treatment groups
(B. G. Guerney, Coufal, & Vogelsong, 1981), and couples communication
(Brock & Joanning, 1983). In each case, RE was shown to be superior on a
majority of outcome measures and at least as effective as the comparison model
on the other outcome measures.
Over the past decade, conflict management skills have been intro-
duced in an effort to reduce negative patterns of interaction. These skills are
designed to help couples diffuse emotionally charged, negative patterns of inter-
action by shifting into structured dialogue mode or, if necessary, a structured

time-out (B. G. Guerney & Scuka, 2005, 2010; Scuka, 2005). In addition,
Scuka (2005) provided a systematic delineation of the theory and practice of
RE therapy that includes an analysis of “deep empathy” as the foundation of
RE and a detailed guide outlining how to conduct RE therapy. This includes
the clinical intake process, the teaching of the core RE skills, and the coaching
of couples in their use of the RE dialogue process. There also is a section dedi-
cated to the treatment of infidelity as well as six clinical vignettes illustrating
the RE therapy process through extended couples’ dialogues.
Primary prevention has always been a major focus of RE. The Mastering
the Mysteries of Love version of RE has been used extensively in the context
of marriage preparation and/or relationship enrichment programs, and it has
added a new forgiveness skill (B. G. Guerney & Ortwein, 2011). A recent
on the Mastering the Mysteries of Love version assessed the impact of three
program components on outcome for 2,940 participants, finding that skills
practice time was most influential, followed by leaders’ presentation time,
whereas group discussion time did not influence outcome (Larsen-Rife &
Early, 2011). Practice time was associated with improved problem solving at
posttest; improved communication at 30-day follow-up; and improved rela-
tionship satisfaction at posttest, 30-day, and 6-month follow-up. Research on
another adaptation of RE called Love’s Cradle (B. G. Guerney & Ortwein,
2008), which supports couples transitioning into parenthood, demonstrated
statistically significant improvements in communication and conflict resolu-
tion, with an average effect size of 0.65 (Wimmer & Gibbs, 2011). Finally,
RE has been translated and reformulated into eight different languages to
attend to the special needs of refugee and immigrant groups (B. G. Guerney,
Ortwein, & Amin, 2009).
Extensive research on FFT, the family version of RE, validates that it is
an effective approach for working with families. VanFleet, Ryan, and Smith
(2005) summarized the foundational research on FFT and reviewed the posi-
tive results of 12 of the most rigorous FFT outcome studies that were included
in the meta-analysis of play therapy research previously referenced (Bratton
et al., 2005). More recently, process research by Topham, Wampler, Titus,
and Rolling (2011) demonstrated that FFT helps parents improve their own
emotional regulation skills, which, in turn, was shown to be significantly
related to parents’ acceptance of their child’s emotion. Moreover, the study
demonstrated improvement in children’s ability to regulate their own emotion
and manage their own behavior better. The authors hypothesized (a) that
parents’ improved capacity to regulate their own emotion is the mediating
factor that helps children better regulate their emotion and (b) that children’s
improved emotional self-regulation mediates their improved behavior self-
management. These hypothesized mechanisms of change in FFT are conso-
nant with its theoretical framework.

Emotion-Focused Therapy for Couples Outcome Research
Since 2000: Working With Diverse Populations
Research on EFT for couples has proliferated over the past 15 years.
A multitude of studies focusing on the efficacy of using this approach with
diverse populations has been conducted by Johnson and her colleagues. Case
studies have also been published demonstrating the application of the model
for specific needs (e.g., sexuality; Johnson & Zuccarini, 2010).
Dalton, Greenman, Classen, and Johnson (2013) conducted the first
controlled trial for couples in which the female partner had experienced child-
hood abuse. Couples were randomly assigned to 22 sessions of EFT (n = 12)
or to a wait-list (n = 10). Couples in the treatment group experienced a sig-
nificant reduction in relationship distress, whereas couples on the wait-list
did not. However, no significant reductions in trauma symptoms were found
for either group.
Couples experiencing ongoing stress related to having a child with a
chronic illness have also benefitted from EFT, as evidenced by Cloutier et al.’s
(2002) findings. These authors examined changes in marital satisfaction for
13 couples who had received 10 sessions of EFT, finding statistically signifi-
cant improvements on the Dyadic Adjustment Scale (Spanier, 1976) scores
between pre- and posttherapy. An examination of clinical change from pre-
treatment to 2 years following the end of therapy revealed that five couples
moved from the “distressed” to the “nondistressed” range on the Dyadic
Adjustment Scale, three couples maintained their gains, four couples showed
no change, and one couple deteriorated.
EFT for couples is also considered an appropriate treatment interven-
tion for depressed women and their partners. An early pilot study compared
the outcome of 12 couples randomly assigned to 16 sessions of EFT or to anti
depressants (Dessaulles, Johnson, & Denton, 2003). The female partners with
depression in both groups demonstrated significant reductions in depressive
symptoms over the course of treatment; however, only the women who received
EFT continued to improve 6 months following the end of treatment. Denton,
Wittenborn, and Golden (2012) compared EFT in combination with anti-
depressants to medication use only. Both groups showed an improvement in
depressive symptoms; however, only the women receiving EFT reported signif-
icant improvement in relationship quality. These findings were echoed in the
analysis by Denton and colleagues (2012), in which 24 couples were randomly
assigned to either 15 sessions of EFT, in combination with antidepressants, or
6 months of antidepressants alone. Significant changes were observed under
both conditions; however, significant improvements in relationship sat-
isfaction were reported only by couples who received both EFT-C and
antidepressants.

Couples from diverse cultural backgrounds have also been shown to ben-
efit from EFT (Greenman, Young, & Johnson, 2009). True to its humanistic
foundation, EFT is inherently culturally sensitive in that couples determine
their concerns and needs, and the meaning-making process that unfolds in
therapy is understood to be a constructive and collaborative one, stemming
from each partner’s lived experience. Working with culturally diverse couples
follows the same EFT protocol, although special consideration is given to
understanding the personal and socially constructed meanings associated with
particular emotional expressions and behaviors (Liu & Wittenborn, 2011).
The use of neuroimaging techniques was at the heart of recent innova-
tive research designed to assess the effects of EFT on the neural processing of
fear (Johnson et al., 2013). The impact of holding hands with another person
under threat of electric shock was examined, using self-reports and functional
magnetic resonance imaging pictures, with 23 couples that had received 13
to 35 sessions of EFT. Spousal handholding (vs. stranger handholding or no
handholding) following EFT had the most profound effects on neural threat
responding. That is, before commencing therapy, holding a spouse’s hand had
no impact on encoding this threat. Holding a partner’s hand posttherapy, how-
ever, was significantly associated with nonactivation of the threatened partner’s
neural stress response and a decrease in rating the pain from the shock. Findings
also revealed that the capacity to self-regulate was enhanced following EFT, as
brain activity indicating anxiety or threat decreased even when the partner
expecting an electric shock was alone. This study provides a rich perspective
into the regulatory mechanisms of close relationships, suggesting that EFT for
couples alters their sense of safety as well as their ability to self-soothe.
Forgiveness
Resolving EIs—understood as betrayals related to issues of attachment
(e.g., infidelity, abandonment during a time of need) and identity (e.g., per-
ceived humiliation)—has been the focus of extensive clinical research since
2000. For example, Greenberg, Warwar, and Malcolm (2010) developed an
effective EFT intervention for resolving EIs. Twenty couples acting as their
own wait-list controls in a 10- to 12-session treatment fared significantly better
compared with the wait-list period on measures of relational satisfaction, trust,
and forgiveness, as well as on global symptoms and target complaints. These
changes were maintained for up to 3 months following therapy, with the excep-
tion of trust, which declined over time. At the end of treatment, 11 couples
were identified as having completely forgiven their partners, and six couples
had made progress toward forgiveness. No one on the wait-list reported hav-
ing completely forgiven, and only three injured partners indicated partial
forgiveness.

Similarly, Makinen and Johnson (2006) developed the attachment
injury resolution model (AIRM) and tested its validity on 24 couples who
had received an average of 13 EFT sessions. At the end of treatment, 15 cou-
ples were considered to have resolved their injuries, reporting significantly
higher levels of relational satisfaction and forgiveness. Gains were maintained
3 years following the end of therapy (Halchuk, Makinen, & Johnson, 2010).
Process Research on EFT for Couples Since 2000

The desire to understand how in-session processes are related to out-
come is one of the hallmarks of EFT research. Ongoing emphasis on studying
vulnerable emotions in-session and exploring the softening event confirms
key postulates of the EFT couples model. Interest has also expanded to study-
ing the resolution of anger and EIs.
McKinnon and Greenberg (2013) assessed the impact of exposing emo-
tional wounds to one’s partner. They studied 25 couples who had received 10
to 12 sessions of EFT, finding that couples rated sessions in which there had
been an expression of vulnerable emotions as being significantly more posi-
tive than other sessions. Moreover, the 12 couples that displayed a vulnerable
emotional expression at least once during the five sessions examined showed
greater improvement at termination, particularly on their ratings of trust
compared to couples in which vulnerability was not observed. Expressions
of vulnerability seem to be associated with short (postsession) and long-term
(posttherapy) gains (McKinnon, 2014).
In an effort to understand the therapist’s role in facilitating the expres-
sion of vulnerability, Bradley and Furrow (2004) conducted a task analysis
on the softening event—a therapeutic event characterized by an expression of
vulnerability typically initiated by the blaming partner that leads to a mutual
sharing of needs (Greenberg & Johnson, 1988). They found that the thera-
pists used evocative responding, heightening, validation, empathic conjec-
ture, and reframing, and they focused on restructuring interactions.
New developments have also been made in the understanding of a
nonvulnerable emotion common to couple therapy—namely, anger. A task
analysis of 15 couples attempting to resolve an EI (Fisher, 2012) revealed that
anger must first be differentiated into attachment-oriented anger (over viola-
tion of trust; loss of security due to betrayal) or identity-oriented anger (over
mistreatment, harsh criticism, or violation of boundaries), although in some
cases both types of anger emerge. Therapist validation of the difficulties that
the listening partner may be experiencing is important (e.g., “You’re sensitive
to hearing her anger. . . . I suspect there is something going on underneath
there for you”) as well as an exploration of the blocks to tolerating the part-
ner’s anger (e.g., “I do have trouble with her anger. It makes me feel bad. You

know, like a piece of shit”). Resolution of anger requires empathic acceptance
and validation of the expressing partner’s anger. This typically leads to the
offending partner taking responsibility for the injury, including expressing
shame, which makes forgiveness more likely to occur.
The investigation of EIs and forgiveness has been a central research
focus for both Johnson and Greenberg and their respective colleagues. The
AIRM (Makinen & Johnson, 2006) evolved from the observation of three
couples who successfully resolved their injuries (Millikin, 2000). Resolution
involves identifying the marker of an injury, its origins, and the negative
interactional cycle that has developed. The injured partner then discloses the
impact of the EI and differentiates the emotions associated with it, whereas
the offending partner attempts to hear this fully, shifting to expressing empa-
thy, remorse, and regret when the injured partner expresses pain over the loss
of the attachment bond. Finally, as the injured partner expresses a need for
comfort, the offending partner’s affiliative response restores the attachment
bond, making way for forgiveness and reconciliation.
The AIRM has been validated through a series of studies based on a
methodology derived from task analysis. Specifically, Makinen and Johnson
(2006) analyzed 24 couples’ self-identified best session on the Experiencing
Scale as well as on the Structural Analysis of Social Behavior system, and they
found that resolved couples displayed significantly more affiliative behavior
and attained higher levels of experiencing than couples who did not resolve
their injuries. In an effort to determine the steps of the AIRM essential to
resolution, Zuccarini, Johnson, Dalgleish, and Makinen (2013) compared
the processes of nine resolved couples with those of nine unresolved couples,
finding that therapy followed the EFT couples model leading up to an injury-
related softening event. For resolved couples, an expression of vulnerabil-
ity by the injured partner was met with empathy, remorse, and an apology,
and it was followed by the injured partner’s expression of attachment needs.
Resolved couples discussed the EI in an emotionally differentiated, integra-
tive, and affiliative manner—a pattern linked to positive outcome (Johnson
& Greenberg, 1988).
Similarly, Meneses and Greenberg (2011) explored via a task analysis
the subtleties of the processes that give way to forgiveness in EFT-C. They
closely studied four couples who reached forgiveness, comparing them to two
couples who did not. This was an exploratory study, representing the discov-
ery phase of a task analysis (Greenberg, 2007); it resulted in the construc-
tion of an empirically based model of interpersonal forgiveness, along with
a rating system of the observed “steps” leading to forgiveness. The valida-
tion phase examined the relationship between selected components from the
task-analytic model and outcome for 33 couples who received 10 to 12 ses-
sions of EFT (Meneses & Greenberg, 2014). Hierarchical regression models

were used to assess the link among the injurer’s expression of shame, the
injured partner’s accepting response to the shame, and the injured partner’s
in-session expression of forgiveness and therapy outcome. An expression of
shame was found to contribute to 33% of the outcome variance in the model
(i.e., forgiveness posttherapy). Adding into the model the injured partner’s
accepting response to the shame explained an additional 9% of the variance,
and in-session forgiveness explained another 8%. The final regression model
accounted for 50% of the variance in forgiveness.
Unlike the AIRM, which emphasizes the injured partner’s expression of
vulnerability as central in moving the forgiveness process forward, Meneses
and Greenberg’s (2014) findings indicate that the offender’s expression of
vulnerability (shame about the injury) is key to interpersonal forgiveness, as
illustrated in this excerpt of therapy with Peter, Johanna, and the therapist:
Peter: I feel bad . . . [looking down]. I’m really, truly, so sorry. I wish
I could change the past.
Therapist: And what happens for you, Johanna, as he says this?
Johanna: [sigh] I’m a bit annoyed, actually. He’s said this before—but
you know, there’s something about how he says it . . . it just
feels empty or without meaning.
Therapist: Peter, can you try speaking to Johanna directly? Look at her
and then speak to her from the heart, so she can feel what
you are saying. She needs to know how this affected you.
Peter: I . . . I . . . um [looking at Johanna] . . . [voice cracks] I can’t even
look at myself in the mirror some days knowing how much I
hurt you. I wish I could have told you about what was going
on for me, instead of sneaking around . . . and damaging what
was most important to me. [crying] I know I really damaged
us . . . It hurts to know I did that.
Johanna: [tearful] Um, I have never heard him say it like this. . . .
[whispering] Thank you.
Therapist: Tell him how it touches you when you see him like this.
Johanna: Uh, it’s actually hard for me to see you, like in your own way
suffering. I always felt alone in my sadness, but now I see he’s
sad too about what happened to us.
Recent Research in Emotion-Focused Family Therapy
Although still in its infancy, existing research in EFFT suggests that this
model is appropriate for working with families experiencing severe clinical
issues. For example, Efron (2004) applied the EFFT model to working with

children struggling with long-term behavioral (e.g., oppositional defiant dis-
order) and emotional problems. In outlining three clinical cases involving
complex family dynamics in which there had been severe attachment inju-
ries (e.g., recovering from a mother’s absence due to incarceration), Efron
described the positive effects on parenting and provided clinical evidence for
EFFT’s efficacy. In one family, the parents became less hostile and punitive
toward their “angry child” once they realized that his anger was secondary to
his feelings of anxiety/discomfort about being part of a blended family and
sadness/hurt at no longer feeling special to his father. When they began to
model interactional patterns that did not emphasize anger, they observed that
their children seemed calmer, less angry, and more pleasant to each other.
Preliminary support for the efficacy of the EFFT model for treatment of
eating disorders is promising. Five parents who participated in eight 2-hour
sessions of an EFFT group (including psychoeducation and experiential EFT
interventions) reported significant improvements in their sense of compe-
tency related to helping their child recover, beliefs about the value of their
child’s negative emotions, and their own emotional regulation abilities
(Kosmerly et al., 2013).
Recent Research on Dyadic Developmental Psychotherapy
Becker-Weidman’s (2006) pilot outcome study assessed the efficacy of

DDP by randomly assigning children who had experienced chronic abuse in
early childhood and met the criteria for reactive attachment disorder to the
DDP group or treatment as usual. The results indicated that, at the end of
therapy and for up to 4 years posttherapy, children in the DDP group showed
a significant decrease in their symptoms, whereas symptoms became more
pronounced for children who received treatment as usual.
A Transcript From an Experiential Relationship Enhancement

Family Therapy Session
The following is a slightly modified transcript from an experiential RE

family session (B. G. Guerney, 1991)1; it involves the mother, the father, their
15-year-old son, and the therapist discussing the son’s behavioral problems
1
From Relationship Enhancement® Family Therapy: Experiential Format (P-Family) [DVD], by B. G. Guerney, Jr.
(therapist), 1991, Silver Spring, MD: IDEALS, Inc. Copyright 1991 by IDEALS, Inc. Adapted with
permission.

and violent behavior. Various RE skills are demonstrated, in particular the
advanced skill of Becoming, intended to facilitate exploration of blocked
emotion, self-disclosure, and insight. After the son declines the therapist’s
invitation to share his feelings, the therapist takes on the son’s identity so as
to empathically represent his experience.
Mother: [empathizing] So, you know I care and that I really appreciate
you. [Places hand on chest, the sign used to indicate a shift into
Expresser mode.] Is there anything I can do to help you?
[depressed, helpless tone] I doubt it.
Son:
Therapist: [coaching] First give your mother an empathic response.
[modeling] You really would like to help me with this.
[quiet, uncomfortable laugh] You would like to help me in this.
Son:
Therapist: [additional modeling] And you’d like to do it in a way that I
would feel okay about.
And you’d like to do it in a way that I feel would be okay.
Son:
[Places hand on chest, shifting into Expresser mode.] But I think
I am the only one who can change myself. No one else can
help me because it’s me, it’s in my head. And you don’t know
what’s in there. And it’s only me. And I’m the one who is
going to have to change it.
Mother: [empathizing] You feel that you are all alone, and you’re the
only one who knows what’s in your head and who can deal
with what’s in your head and can change yourself. [pause]
But you’ve expressed a desire to change. You want to change.
Therapist: [prompting to Son] I think it would be helpful if you would
share some of the things that you struggle with. [shifts to
troubleshooting/empathizing] You say you’ve got things in
your head related to this that get in the way. And . . . you’re
not sure. Your thoughts are that the family can’t help; you
have to do it yourself.
Um . . . hmm.
Son:
Therapist: [additional prompting] But I think I can help, if we learn more
about what those things are. . . . I might have some ideas or
ways that I can suggest. . . . But it’s true, we have to know
some of the things that you struggle about, some of the fears,
some of what you want, what gets in the way of what you
want to do.
[halting speech, essentially hopeless] I don’t really want to talk
Son:
about it. It’s already . . . That’s just forgotten . . . Pretty much
of it.

Therapist: Between you and your brother, is that what you’re talking
about?
[withdrawn, quiet] My older brothers, what they did to me. I
Son:
don’t know why . . .
Therapist: [proposes becoming the son] Okay. That gives me some ideas.
[pause] I’d like to speak for [Son] then, and see if at least
you could perhaps tell me if I am on the right track or the
wrong track about that. I can see it’s difficult for you to talk
about it.
[correcting therapist’s empathy] [quiet, hopeless] No, it’s not.
Son:
Therapist: [troubleshooting/empathizing] It’s not that difficult. It’s just that
you’re kind of hopeless about it doing any good.
[discouraged] It’s just . . . It’s already happened. I can’t change it.
Son:
Therapist: [troubleshooting/empathizing] So it’s this kind of feeling: It’s
futile to talk about it. It’s not so hard to talk about, but it
won’t do much good because it’s . . .
[interrupting] It won’t do much good.
Son:
Therapist: Well, I feel it might. And I think your parents would like
to know very much what these things are. [Son winces and
shakes his head.] Maybe they have some ideas.
[suddenly animated, emphatic, and angry] They know! They
Son:
should know. The times [my older brothers] beat me up. [Brian]
picked me up by my neck and threw me against the wall.
Therapist: [addressing the parents] Do you feel that you know what he’s
talking about? Could you identify with what he’s saying?
[invites one of the parents to become the son]
Father: I might know some of it. I don’t think I know all of it.
Therapist: [addressing the father] Could you put yourself in his place?
Help him express it?
Father: [looks helpless, doesn’t explicitly answer, implying he doesn’t feel
he can]
Therapist: [addressing the mother] Could you talk? I think there would
be a lot of anger, a lot of rage at being treated that way.
And maybe even . . . [The therapist picks up on the mother’s
reluctance as well, and shifts gears.] Do you want me to do
it? To try it?
Father: Yes. I’m feeling a lot of mixed emotions.
Therapist: [to the Son] Let me try it. I think your parents may know what
happened, but they may not know how much it means to

you or how it relates to your anger. [pause] If I’m going off
track, could you just give me a tap? [Son nods affirmatively.]
[It is important that the client be given permission to correct
the therapist if necessary.]
Therapist: [initiates Becoming, speaking to the parents as Son] I think you
know what happened, but I’m not sure you know how much
anger I have inside of me because of the way I was beaten
up by my brothers. I felt I was terribly abused, and even felt
scared to death at times. I felt my life was in danger. I felt
tremendous fear and anger and frustration, and a desire to
strike back. A lot of rage about not being able to defend
myself, or to hurt those who were hurting me like I wanted
to do. [seeks confirmation from the son] Is that all true? [Son
nods affirmatively.]
Therapist: [continuing Becoming mode] And I carry that around with me.
I have a lot of anger, rage, and resentment toward my older
brothers. It’s always within me. And sometimes it jumps out.
[seeks confirmation from Son] Does that feel right? [Son gives
affirmative nod.]
Therapist: [continuing Becoming mode] And I do struggle with it, because
I do appreciate what you are trying to do for all of us. I appre-
ciate that enormously, and your sharing and your telling us
that you care for us, and your willingness to help us. But I
still carry all of those feelings around. And that’s my struggle,
because the way you’re acting now is so different. So I’m
struggling to do that better, to control [my anger], and be a
constructive person in the family, but [my anger] just pops
out of me sometimes. [seeks confirmation from Son] Is that
correct? [Son gives affirmative nod.]
[now expressing for himself] [more animated, with angry but con-
Son:
trolled tone] Well, sometimes I feel like I just want to kill
someone. If they’re bugging me, I can feel my hands [clenches
his right fist several times], they start to contract and I just get
mad. It seems like there’s smoke coming out of my ears. And
I can feel it swelling up inside me, and I just . . . I just punch
the wall or something.
Therapist: [continuing Becoming mode] So I want you to understand how
hard it is for me to struggle against that. I’m willing to hurt
myself to keep from doing that. But it’s a constant battle
because of what was done to me and the rage I felt about it.
When someone makes me angry it all comes up . . . It’s hard
to stop it, as much as I want to.

[again expressing for himself ] Part of the way I acted at school
Son:
is probably part of how they treated me. When I threw that
kid over the desk, it was probably part of how what they did
affected me.
Therapist: [prompt to Mother] Could you empathize?
Mother: [empathizing with Son] [tentatively, but with genuine caring in her
voice] So you feel very angry. You have a lot of anger, a lot
of hate, a lot of rage inside of you as a result of the way your
older brothers treated you. And, because of that, it’s very
difficult for you, even though we love and appreciate you,
and we’ve changed the way the family runs now, it’s very dif-
ficult for you to control that anger. It’s so much a part of you.
It’s even spilled over into other parts of your life, not just
with your family, but in the way you treat people at school,
and the way you behave. You have felt so much anger there
was smoke coming out of your ears. You would hit a wall
to avoid hurting someone else. That’s how much anger you
carry inside of you.
Therapist: [resuming Becoming mode] I’m even afraid sometimes that I’m
capable of killing somebody if that gets out of hand. [turns
toward Son] Is that going too far?
[quietly] A little too far.
Son:
Therapist: [empathically reinforcing Son’s disclaimer] A little too far. But
almost.
Mother: [empathizing] You’re angry almost to the point of wanting to
hurt somebody.
[uncertain, and a little afraid] I mean, like if I start beating up
Son:
[my younger brother], I laugh and I think it’s funny. [pause]
Tell me if I’m crazy. [quiet laugh]
Mother: [empathizing] You’re saying that you feel that the kind of
anger you have is not normal, and it scares you, the way
you feel when you start hitting your brother. It scares you,
because you’re getting some enjoyment out of that and that’s
what scares you, the enjoyment you get in hurting someone
else. [Son nods affirmatively.]
Mother: [switching to Expresser mode] I’d like to respond. [surprised
tone] I wasn’t aware of the depth of your anger, so I’m feel-
ing now that, when I ask you to control your anger, it’s
really asking an awful lot of you. [Mother shakes her head.]

I’m just amazed at the effect, amazed at what you’re feeling.
[big sigh] . . . though I think part of me has known that
somehow this was serious, very serious . . . [frightened tone]
and it scares me.
I just want to stop. I don’t want to talk about that anymore.
Son:
[The therapist closes the session by acknowledging how diffi-
cult this was for the son. The parents (via the therapist) express
appreciation for his efforts to control his behavior and his desire to
change. They also express a desire to help him.]
Mother: [hopeful tone] I feel very touched and I feel good because,
now that I know, I feel I can understand what you’re going
through a bit better. I feel determined to try to help . . .
with how you deal with the anger, since it seems to me that
this is something that you would like to get a grip on . . .
a burden that you would like to get rid of. I am willing to
help you in any way I can, to get rid of that burden, to do
whatever it takes.
This powerful family dialogue illustrates the emotional depth of the
RE process and how the therapist’s use of Becoming can open up a client’s
blocked emotions. The therapist’s deep empathic representation primes the
son’s “emotional pump” so that he can take ownership of his own experience
and speak for himself. Insight and personal transformation are promoted,
particularly when the therapist asks the son, “Is that going too far?” (refer-
ring to the son’s statement about feeling like he wants to kill someone), and
he responds, “A little too far.” In that pivotal moment he reclaims his life by
affirming the life path he does not want for himself.
A Case Illustration of Emotion-Focused Therapy for Couples
Johnson (1996, 2004) organized the 1988 EFT model into three stages:
(a) cycle deescalation, (b) restructuring of interactions, and (c) integra-
tion and consolidation. As noted previously, Johnson focused on working
with attachment (i.e., closeness) in her approach to EFT. In contrast,
Greenberg and Goldman (2008) expanded on the original EFT framework
by proposing a five-stage treatment model that addresses the dimensions of
attachment and identity (validation; self-worth). In brief, Greenberg and
Goldman’s approach to EFT includes the following stages: (a) validating each
partner’s current position and forming an alliance, before working on (b) neg-
ative cycle deescalation. This is followed by (c) accessing underlying vulner-
able feelings, and (d) restructuring the negative interaction and the self, where
the emphasis is on acceptance of expressed vulnerability and exploration of

difficulties that may arise for one or both of the partners in this process. The
therapist facilitates an in-session enactment by encouraging partners to turn
toward each other and express, as well as respond to, each other’s feelings and
needs, generating a new way of interacting for the couple. Self-soothing work
may be introduced to transform maladaptive emotional responses predating
the relationship (R. N. Goldman & Greenberg, 2013). Finally, the couple
moves to (e) integration and consolidation.
The following transcripts come from an EFT-C session conducted by
the therapist, L. S. Greenberg (personal communication, 2013) with Sophia
and Richard, focusing on their loss of intimate connection.
Stages 1 and 2: Validation and Alliance Formation; Negative Cycle Deescalation

Sophia: On the weekend I will admit that I exploded. It was so beau-
tiful on Sunday and I suggested going for a drive to the coun-
try, and you know, maybe having a picnic by the lake, and he
just looked at me and said he had to fix the shower.
Therapist: So it sounds like you’re saying that you were disappointed.
Sophia: Absolutely! Sometimes I even wonder if he even wants to be
with me.
Therapist: So somehow that comes out as anger, especially when you
feel your needs are not being met.
Sophia: In the past I would yell and scream, but now I know there’s
no point. So I go do something nurturing for me, you know,
with my daughter and my friends, or by reading.
Therapist: Right, right, so you take the initiative to take care of yourself
during these moments. But my sense is that can only go so
far, until you have to have a connection with him. And what
happens for you, Richard?
Richard: Sometimes it’s like I don’t know what to do when she tells
me that she needs this or that. I didn’t grow up in a family
where we talked about emotion or needs. It’s uh . . .
Therapist: Right, right. So it’s difficult for you to make sense of her
reactions, given your history. But at the same time she’s like
a plant needing water. If you are not able to nurture her, she
starts feeling deserted, and she gets really angry, but actually
she’s feeling quite alone. And it sounds like you’re saying
you’re feeling a bit unsure at those times, so you retreat and
busy yourself.
Richard: Right, I just can’t handle all the tension.

Therapist: And part of what keeps this cycle going is that your with-
drawing triggers her sense of loneliness, so she comes forward
more forcefully, and so we need to work on getting the two
of you unhooked from this cycle.
Stages 3 and 4: Accessing Underlying Feelings and Restructuring

the Negative Interaction
Therapist: Try to connect with that feeling of loneliness and see if you
can put some words to it.
Sophia: [sighs] I, uh, I’m not sure where to begin . . .
Therapist: Mm-mm, so take a moment and see if you can first locate
that feeling in your body and then just try to see what’s there.
Sophia: It’s in my chest, and it just, uh, [tearful] feels really heavy—
and sad. [crying]
Therapist: Right. “I feel really alone sometimes and I need you to be
closer.” Richard, what’s it like for you when she says she is
lonely and she needs closeness?
Richard: It’s hard. It’s like she’s saying that I’ve let her down because
I didn’t meet her expectations.
Therapist: Somehow it makes you feel like you have failed her, or that
you’re inadequate
Richard: Right, that she is demanding more from me and I don’t know
if I can give her that closeness.
Therapist: Tell her what you feel right now.
Richard: When you tell me that you’re lonely, and tell me that you
want more closeness, it makes me feel bad. Like I have let
you down . . . that I failed, and then I feel inadequate.
Sophia: [sigh] It’s like I can’t express anything without him feeling
that I am criticizing him and oomph! He puts up a wall.
Therapist: So what we have is two very different people with very dif-
ferent needs, and each one is actually legitimate and valid.
Yet somehow his withdrawal invalidates you by not giving
you what you need, and he says that you overreact. You are
very sensitive when he says that, and he withdraws, feeling
inadequate inside.
Sophia: I just don’t know what to say. I’m feeling hurt, and alone, and
he’s behind his wall.
Therapist: So what happens inside? She’s saying this quite intensely. . . .
Do you tighten up?

Richard: I don’t know. . . . I guess I tend to . . . back away a little bit.
Sophia: As soon as I say that I am angry with him, he feels unloved. I
can see it in the look on his face. All of a sudden, there is this
look of a little boy: “What? You don’t love me anymore?” He
once told me that in his house when people got angry they
never made up.
Therapist: Do you feel unloved? Is it scary for you? You say you pull
away.
Richard: It’s more the feeling that I am unable to cope with what’s
happening—with her emotions.
Therapist: I don’t know how to handle this? It is a bit overwhelming.
Richard: Yes! It’s like, how do I make it all better again? I feel I have
a need to make it all better.
[In a later session, Sophia describes the physical disconnection
in the relationship.]
Sophia: And I’m watching the movie thinking—Ha! He doesn’t
have the feeling where you want to kiss somebody. [crying]
It’s just not there.
Therapist: So it feels like this kind of passionate love is missing, and
that makes you feel unloved.
Sophia: I feel like he is my friend.
Richard: I don’t know what to say. I’m sorry I’m a disappointment
to you.
Therapist: So this activates something deep in you, like “I am no good.”
And left alone this can escalate. Sophia, you can feel quite
unloved, and you, Richard, can feel very inadequate.
Sophia: This is not a criticism.
Therapist: Yes, yes, I understand you are actually saying “I feel very
lonely. I miss the passion.” My sense is that Richard may also
miss that. What’s your sense about the kissing?
Richard: I am aware of it, but it’s tied in with my state of mind, um,
and that’s got to do with how Sophia is feeling. When I feel
that she’s not comfortable or happy, it affects me.
Therapist: So you’re sensitive to her, and if you feel she’s unhappy, there
is an implicit criticism in that for you, like “I am not meeting
her needs.” So you tend to tense up and withdraw, which is
the opposite of what she wants. Can you tell her what it’s
like behind the wall?

Richard: [sigh] Uh, behind the wall is very lonely and confusing . . .
because I just drown in bad thoughts. I can’t seem to . . . [looks
down] like I can’t find my sense of self-worth.
Therapist: So behind the wall you are feeling like “I am not OK, not
good enough, or I am failing.”
Richard: Hmmm. And then I think, if I stay behind and shut everyone
out, it’s better.
Therapist: Therefore you put up the wall to hide, so there is sort of . . .
a sense of embarrassment?
Richard: Yeah, because if they knew how I was feeling or thinking
they would think . . . uh, that I am no good, and they would
leave me.
Therapist: So it’s like you’re saying to her, “I am afraid that you would
think badly of me if you knew who I am behind the wall.
And so it is hard for me to show you.”
Sophia: But it’s precisely what has always attracted me to him and
kept our bond, that he’s this frightened, needy, lonely boy. I
want to love him and make him better.
Therapist: So when he says that, you are really moved. Tell him about
this.
Sophia: [tearful] Yeah. I want to help you. I mean I love you, and I
know that part is there, and then when you push me away,
it’s really hard for me to be loving towards you.
Therapist: He smiled when you said that.
Richard: I always imagined or envisioned a different reaction . . .
never like a reaction of love. I know you’ve never reacted
any other way, but it’s like I am always expecting the worst.
Therapist: So you see the love rather than the disapproval, and when
you, Sophia, see the little flag from the frightened child, you
are quite able to respond.
Sophia: I haven’t seen that frightened child for years because of the
walls. For me it’s been like the frightened child has been
pushing me away, and then I don’t feel needed.
Richard: Uh, but the frightened child has also seen the other side of
you . . . like the witch side, and that frightened child is very,
very afraid of the witch and so closes off.
Sophia: Are you calling me a witch? [laughs]
Richard: You know what I mean.

Therapist: And this is why I also want you to see her lonely child who
drives the witch. [laughter from both] The witch is not really
the witch; the wall is not really the wall.
Sophia: I’m putting that on the fridge! The underlying parts need to
talk more to each other.
Stage 5: Consolidation and Integration

Therapist: So it sounds like things between the two of you have improved.
Sophia: Yes, it’s taken a lot of effort, but I’m feeling closer to Richard
than I have in years.
Richard: This has been really helpful in terms of having me reflect on
how we’ve evolved and also how it’s been for Sophia. I feel
like I’ve learned a lot about her . . . well, both of us.
Therapist: And what would it take for you two to get back into your
cycle?
Richard: I think if I reverted back to my tendency of expecting her
to reassure me, instead of remembering the way we worked
with my memories of being a little boy, um, then I would
probably start feeling really down about myself and we would
be in trouble, because I would put up my walls, as she says,
and not be able to come out to reassure her.
Sophia: Well, I also have a role in this.
Richard: Of course you do. [laughs]
Sophia: If, instead of showing him my lonely side, the witch comes
out, then I know he would retreat because I can be scary.
[laughs] So I have to be more direct, but also soft.
CONCLUSION
Humanistic approaches to couple and family work have evolved tremen-

dously over the past decades, due in large part to the contribution of research
findings. There is now a sense that different types of processes are necessary for
different types of problems, and that emotional expression and regulation are
central to transforming dysfunctional patterns within a system. The approaches
outlined in this chapter have succeeded by maintaining the integrity of their
philosophical roots, while continuing to be process-oriented even while further
systematizing and integrating the various therapeutic approaches. It is hoped
that this will continue to be the case, even as knowledge is enhanced and
theories are refined.

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148–162. http://dx.doi.org/10.1111/j.1752-0606.2012.00287.x

12
HUMANISTIC PSYCHOTHERAPY
WITH CHILDREN
DEE C. RAY AND KIMBERLY M. JAYNE
Children represent a distinct population in the world of psychotherapy,

deserving of special consideration when exploring therapeutic outcomes.
Because of children’s developmental worldview and differential verbal abilities
from adults, humanistic outcome research can be challenging to design, mea-
sure, and interpret. Elliott, Greenberg, Watson, Timulak, and Friere (2013)
suggested that humanistic therapies have common philosophical principles,
including centrality of the therapeutic relationship as healing, importance of
the client experiencing of process, value of the client’s internal experience as
a guide, and genuine concern and respect for each person as a holistic individ-
ual (not as a symptom or diagnosis). The most significant common principle
among humanistic therapies is the belief in the relationship between client
and therapist. Mearns and Cooper (2012) introduced the concept of working
at relational depth as a way to unleash the curative factors of the therapeutic
http://dx.doi.org/10.1037/14775-013
S. Rubin (Editors)
387
relationship, and they defined the therapist’s experience of relational depth
as follows:
A feeling of profound contact and engagement with a client, in which
one simultaneously experiences high and consistent levels of empathy
and acceptance toward that Other, and relates to them in a highly trans-
parent way. In this relationship, the client is experienced as acknowl-
edging one’s empathy, acceptance and congruence—either implicitly or
explicitly—and is experienced as fully congruent in that moment. (p. 36)
Mearns and Cooper (2012) further proposed that this relational depth
is constructive to all forms of therapy and is related to more meaningful and
successful outcomes. In child psychotherapy, the need for relational depth
as well as the demonstration of high levels of empathic understanding and
unconditional positive regard through genuine presentation of self are often
dismissed (Ray, 2011) or viewed as unessential when working with children
(Wilson & Ryan, 2005). Although obvious, many therapists may need to
be reminded that children are people who respond to relational variables as
people of various ages do. Just as adults benefit from deep levels of relational
contact to work through their most troubling issues, children require the same
quality of contact.
The most observable difference between humanistic work with children
and work with adults involves the nature, intensity, and quantity of verbal
contact. Children use play as their language (Landreth, 2012), drawing on
toys, artwork, and scenes as a way to express their internal and external expe-
riences. The therapist’s ability to provide an environment facilitating full and
free expression of those experiences and the child’s ability to accept that envi-
ronment is the core of the therapeutic relationship. The self of the therapist,
which is central to the therapeutic environment, requires provision of open-
ness to relational depth with the child. Because children are individuals, some
may respond to a therapist’s provision of empathic understanding, uncondi-
tional positive regard, and genuineness in a verbal way, but the majority of
children respond nonverbally through play, touch, physical proximity, and
uninhibited expression of internal experiences through play materials. Hence,
the humanistic child therapist offers self, as well as an environment, in a way
that provides multiple materials for expression, space to move, and freedom
to express at a self-directed pace.
To provide an environment that is conducive to relational depth with
a child, humanistic therapists are apt to incorporate expressive materials into
their interventions. The most common approach to humanistic interven-
tion with children is play therapy. Anna Freud (1946) first acknowledged
the importance of the therapist–child relationship within play therapy by cit-
ing the need for the child to establish an attachment to the therapist before
analysis of nondirective play could be successful. Virginia Axline (1947), a
388 ray and jayne

student and colleague of Carl Rogers (1942), structured the philosophy of
person-centered theory in a developmentally responsive manner in her work
with children by providing an environment conducive to their natural way
of communicating through play. This environment consisted of a playroom
of specific toys that allowed children to express their inner selves. The devel-
opment of the therapeutic relationship within the context of the playroom
provided children a safe environment for both verbal and nonverbal expres-
sion. Axline labeled her approach to play therapy as nondirective, currently
referred to as child-centered play therapy (CCPT), highlighting the person-
centered therapist attitudinal conditions of unconditional positive regard,
empathic understanding, and congruence.
Axline (1947) offered guidelines to enact the philosophy and thera-
peutic conditions described by Rogers (1942). These guidelines, which helped
define the nature of CCPT and the role of the therapist, continue to guide prac-
tice today. Referred to as the Eight Basic Principles (Axline, 1947, pp. 73–74),
the guidelines are paraphrased below:
1. The therapist develops a warm, friendly relationship with the
child as soon as possible.
2. The therapist accepts the child exactly as is, not wishing the
child were different in some way.
3. The therapist establishes a feeling of permissiveness in the rela-
tionship so that the child can fully express thoughts and feelings.
4. The therapist is attuned to the child’s feelings and reflects those
back to the child to help gain insight into behavior.
5. The therapist respects the child’s ability to solve problems,
leaving the responsibility to make choices to the child.
6. The therapist does not direct the child’s behavior or conversa-
tion. The therapist follows the child.
7. The therapist does not attempt to rush therapy, recognizing the
gradual nature of the therapeutic process.
8. The therapist sets only those limits that anchor the child to real-
ity or make the child aware of responsibilities in the relationship.
Although CCPT emerged as a defined approach to play therapy, rela-
tionally based play therapy has contributed significantly to its definition and
practice. Clark Moustakas (1997), deriving his approach from an existential-
humanistic philosophy (Moustakas, 1959), presented essential conditions
for relationship play therapy, including respect for the uniqueness of the
child, focus on the present experience, therapist empathy for and unquali-
fied acceptance of the child, and freedom of expression for the child. Haim
Ginott (1959) also contributed to the relational focus in play therapy by
suggesting full permissiveness in the therapist–child relationship that allows
humanistic psychotherapy with children 389

for all verbal and symbolic expression of feelings. Ginott further applied his
relational approach to the parent–child relationship. Axline, Moustakas, and
Ginott were the pioneers of applying humanistic principles to child therapy.
Landreth (2012) led the continued development of CCPT in recent decades,
whereas Oaklander (1988) popularized the play therapy approach from a
Gestalt perspective, encouraging children’s full expression and self-awareness
through the use of creative materials.
Of the humanistic approaches to play therapy, CCPT is recognized as
the most popular one in the United States (Lambert et al., 2007). It enjoys
a strong international reputation (see West, 1996; Wilson, Kendrick, &
Ryan, 1992). CCPT is procedurally defined in several volumes of literature,
all in agreement on its basic tenets and structure (Axline, 1947; Cochran,
Nordling, & Cochran, 2010; Landreth, 2012; Ray, 2011; VanFleet, Sywulak,
& Sniscak, 2010). Play therapists use a playroom with carefully selected toys
to match the developmentally appropriate communication style of children,
thereby supporting the message that the play therapist seeks to understand the
whole child in the context of his or her world. By understanding and accept-
ing the child’s world, the play therapist offers the child an environment that
unleashes the child’s potential to move toward self-enhancing ways of being.
CCPT distinguishes the therapist–child relationship as the healing agent in
therapy, requiring that therapists meet children with a deep level of con-
gruence, empathic understanding, and unconditional positive regard while
acknowledging the unique personhood of each child in ability and willing-
ness to experience those conditions (Ray, 2011). Axline (1947) encouraged
a truly permissive environment to facilitate a child’s full self-expression and
to remove any perceived threats to the child’s self-structure. Nondirectivity
on the part of the therapist is a reflection of the therapist’s ultimate belief in
the child’s self-actualizing tendency and fundamental trust in the child’s abil-
ity to lead the therapeutic process in the most growth-promoting direction.
Within this nondirective framework, the therapist actively and intention-
ally strives to provide an environment and relational presence characterized
by congruence, empathy, and unconditional positive regard to promote the
child’s integrity and trust in his or her own experience and tendency to move
toward healthy development.
SUMMARY OF MAJOR RESEARCH FINDINGS TO 2000
In conducting a historical review of humanistic intervention research

with children for the present chapter, there were no identified summaries
specific to child humanistic therapies. In a meta-analysis of treatment out-
come studies for children and adolescents, Weisz, Weiss, Han, Granger, and
390 ray and jayne

Morton (1995) categorized all nonbehavioral treatments together, thereby
presenting difficulty in assessing outcomes of humanistic therapies. Weisz
et al. reported a small effect size for six client-centered studies, although
details on these studies were not provided. Hölldampf, Behr, and Crawford
(2012) reviewed humanistic outcome studies that included child and ado-
lescent research, along with parent intervention studies from 1942 to 2010.
Their summary concluded that all reviewed studies provided support for
person-centered and experiential therapies when compared to control groups,
with the highest benefits for children and adolescents with anxiety symptoms.
Hölldampf et al. also noted that many of the reviewed studies encompassed
a combination of problems and complex situations, lending credibility to the
conclusion that humanistic therapies work.
Bratton and Ray (2000, 2002) reviewed research spanning six decades
conducted on humanistic play therapy specific to young children. They iden-
tified the fundamental principles of humanistic play therapy as belief in the
phenomenal world of the child; belief in the child’s natural striving toward
growth, mastery, and maturity; belief in the child’s capacity for self-evaluation,
self-regulation, and self-direction; and belief in the importance of the
therapist–child relationship in facilitating the child’s growth. They iden-
tified 82 play therapy experimental studies, with 48 considered as humanis-
tic play therapy, published from 1940 to 2000. Across decades, play therapy
research continued to increase from the 1940s until the 1970s, when it peaked
with a record of 23 identified experimental studies. Research leveled off in
the 1980s and 1990s, resting at 16–17 studies in each decade, respectively.
CCPT has a long history of research spanning over 60 years. In the ear-
liest identified study, Dulsky (1942) attempted to examine the relationship
between intellect and emotional problems. He inadvertently established the
effectiveness of nondirective play therapy, which significantly improved social
and emotional adjustments, although no improvement was shown on intel-
lect. Early play therapy research was marked by flaws in design, such as the lack
of a control or comparison group, random assignment, detailed description of
participants, and detailed description of intervention. Additionally, Bratton
and Ray (2002) reported that the lack of intervention description was par-
ticularly problematic in the identification of humanistic play therapy studies,
as humanistic studies may be classified as nondirective, client-centered, self-
directed, relationship-oriented, or unspecified at all. Ray (2011) reviewed only
CCPT studies, finding a total of 63 studies conducted from 1940 to 2010, indi-
cating that CCPT studies appeared to have increased in the new millennium.
Additionally, all 63 of the studies demonstrated some positive outcomes for
CCPT. Bratton and Ray (2000, 2002) concluded that historical humanistic
play therapy research demonstrated positive outcomes in the areas of self-
concept, behavioral change, anxiety/fear, cognitive ability, and social skills.

Perhaps the best way to grasp the effectiveness of humanistic play ther-
apy in historical research is through meta-analyses conducted by LeBlanc and
Ritchie (2001) and Bratton, Ray, Rhine, and Jones (2005), two studies carried
out independently. LeBlanc and Ritchie conducted the first meta-analysis to
focus exclusively on play therapy studies, reporting a moderate treatment effect
size of 0.66 standard deviations for the 42 controlled studies included in their
analysis. LeBlanc and Ritchie further reported that the average age of partici-
pants was 7.9 years, with duration of therapy and parent involvement as sig-
nificant predictors of effectiveness. Although results revealed that play therapy
was an effective intervention for children, the authors did not differentiate
between humanistic and nonhumanistic play therapy interventions.
Bratton et al. (2005) looked at 67 play therapy studies published from
1942 to 2000 in their meta-analysis, reporting a large effect size (d = 0.72).
Similar to LeBlanc and Ritchie (2001), Bratton et al. reported the average
age of study participants as 7.0 years. Consistent findings from Bratton et al.
and LeBlanc and Ritchie indicate that play therapy is an effective interven-
tion for younger children, especially when it is compared to interventions for
older children included in other meta-analyses and reviews (i.e., 10.5 years
in Weisz et al., 1995). Bratton et al. reported moderate to large effect sizes for
internalizing (d = 0.81), externalizing (d = 0.79), and combined (d = 0.93)
problems. Both humanistic play therapy (d = 0.92) and nonhumanistic or
behavioral play therapy (d = 0.71) approaches were considered to be effective
regardless of theoretical approach. However, the effect size for humanistic
play therapy was deemed to be in the large effect category, whereas the effect
size for nonhumanistic interventions fell in the moderate category. Bratton
et al. concluded that play therapy appeared effective across settings and pre-
senting problems, although future play therapy studies needed to adhere to
rigorous design, analysis, and reporting guidelines for research to be consid-
ered evidence-based.
CURRENT LITERATURE REVIEW: 2000 TO PRESENT
To identify humanistic child studies published since 2000, in the present

review we used the following inclusion criteria: (a) studies reporting descrip-
tive information on intervention, (b) interventions identified as humanistic
or aligned with a humanistically based philosophy, (c) participants between 3
and 13 years of age, (d) studies using and reporting quantitative measures to
evaluate interventions, and (e) studies published in peer-reviewed journals or
books. Several studies published as dissertations or theses were initially identi-
fied but ultimately were excluded from the review because of a number of con-
cerns regarding quality of design, intervention, analyses, and interpretation
392 ray and jayne

of results. Studies exploring humanistic interventions with children more
than 13 years of age were not included because of the major differences in
therapeutic approach and developmental needs between young children
and adolescents. The majority of identified studies used the exploration of
CCPT, whereas a few studies examined the effects of interventions described
as humanistic or humanistically based. After hundreds of potential studies
were reviewed for inclusion, 32 met the criteria, of which 17 were experimen-
tal group designs, three were quasi-experimental group designs, three were
experimental single-case designs, and nine were repeated-measures single-
group designs. In comparison, Hölldampf et al. (2012) also identified 32 pub-
lished humanistic studies since 2000 for their review; however, these studies
included both children and adolescents. Bratton and Ray (2002) reviewed
48 studies meeting the criteria for play therapy studies that were humanisti-
cally based, considered experimental designs, and published over six decades
(from 1940 to 2000). The number of studies conducted since 2000 represents
a substantial increase from previous decades.
CCPT, also referred to as client-centered and nondirective play therapy,
was used as the independent variable in 27 of the 32 studies. Three studies
identified a play-based intervention—for example, sand tray, art, and activ-
ity therapy—grounded in humanistic principles. Finally, one study examined
the impact of Gestalt play therapy. The one study, by Shechtman and Pastor
(2005), that did not utilize an expressive arts medium as part of the humanistic
intervention still incorporated some play activities into the protocol. There
appears to be a consensus that humanistic interventions for children heav-
ily integrate the use of play as a way to speak the developmental language of
children and, by extension, to develop effective therapeutic relationships with
children (Landreth, 2012). The frequency of CCPT as the identified inter-
vention marks an evolution in the study of play therapy. In previous reviews,
Bratton and Ray (2002) and Ray (2006) found that humanistically based play
therapy was historically referred to by a diversity of titles, such as nondirec-
tive, client-centered, self-directed, or relationship-oriented. The movement
toward using the title CCPT may indicate a unification of the person-centered
approach to play therapy. Additionally, the development and publication of
the CCPT manual (Ray, 2009, 2011) aided in a clear identification of the
process and protocol of CCPT available for research exploration. There was
a noticeable absence of interventions from other humanistic orientations.
Gestalt and existentially based play therapies, popularized through the works
of Oaklander (1988) and Moustakas (1997), have a limited research base; yet,
these therapies maintain a distinct presence in the literature and practice of
counseling with children.
Researchers in the new millennium explored multiple topics in the study
of humanistic play therapy interventions. Historically, these studies examined

the effects of play therapy on cognitive abilities, social skills and standing, self-
concept, and behavior. Recent play therapies continue to focus on behaviors
but less so on social adjustment and self-concept. The early studies of cognitive
abilities have evolved to focus on academic achievement and skills while less
concentrated on intellectual capacity. Newer topics, such as trauma, function-
ality, and relationship, have emerged as more relevant to current concerns. In
the following review, we describe recent studies under the primary categories
of externalizing, internalizing, self-concept, and recent topics of focus.
Externalizing/Disruptive Behaviors
Child counseling intervention research is replete with studies on external-

izing problem behaviors of children, usually referred to as disruptive behaviors.
Disruptive behavior problems, including aggression, opposition, hyperactivity,
and impulsivity, are demonstrated by a high number of young children; with-
out intervention, they typically increase over time (Comer, Chow, Chan,
Cooper-Vince, & Wilson, 2013; Studts & van Zyl, 2013). Most interventions
for disruptive behaviors are rooted in behavioral therapies. Yet, recent studies
have yielded strong support for the use of humanistic play interventions with
disruptive behaviors.
Ray, Blanco, Sullivan, and Holliman (2009) assigned 41 children, ages 4
through 11, to a CCPT group or to a no-intervention control group. Children
who received 14 sessions of CCPT twice a week for 7 weeks demonstrated a
decrease in aggressive behaviors compared to children in a control group, as
measured by parents and teachers. The authors concluded that the therapist’s
understanding and acceptance of aggressive feelings and behaviors expressed in
play therapy satisfied the children’s need to express their anger and aggression
behaviorally. In other words, experiencing acceptance and empathy toward
their aggressive behavior in play therapy increased children’s ability to express
such feelings in socially acceptable ways outside the playroom. Bratton et al.
(2013) randomly assigned 54 preschoolers identified with disruptive behaviors
to CCPT or to an active control reading intervention. Children who partici-
pated in 17 to 21 sessions of play therapy demonstrated statistically signifi-
cant decreases in externalizing behaviors compared to those in active control
intervention as measured by teachers. The authors of this study attributed the
decrease in disruptive behaviors to children’s increased experience of empathy
and the provision of play materials to express their feelings within the safety
and limits of the therapeutic relationship. Schumann (2010) compared the
results of 37 children with aggressive behaviors who were assigned to CCPT
or to an evidence-based school guidance program. Following 12 to 15 sessions
of CCPT or evidence-based guidance, children in both groups demonstrated
statistically significant decreases in aggressive behavior. The author concluded
394 ray and jayne

that CCPT was effective in addressing the most challenging behaviors of chil-
dren within the school setting.
Garza and Bratton (2005) explored the use of CCPT specifically with
29 Latino/a children demonstrating behavioral problems. Children partici-
pating in 15 sessions of CCPT demonstrated statistically significant decreases
over the comparison guidance intervention in externalizing behaviors. Fall,
Navelski, and Welch (2002) found that children who participated in six ses-
sions of CCPT decreased problematic behavior more than children in a no-
intervention control condition as measured by teachers. Flahive and Ray
(2007) explored the use of the humanistic sand tray process with 56 children
identified with behavioral problems. Children participating in 10 sessions of
group sand tray therapy decreased externalizing behaviors at a statistically sig-
nificant level compared to the control condition as measured by parents and
teachers. Across studies, humanistic interventions have been found effective
in reducing externalizing and problematic behaviors that are among the most
common reasons why children are referred to counseling.
The disruptive behaviors associated with attention-deficit/hyperactivity
disorder (ADHD) include impulsivity, inattentiveness, and hyperactivity. A
few studies have explored the use of CCPT with children who exhibit these
symptoms. Ray, Schottelkorb, and Tsai (2007) randomly assigned 60 children
to a CCPT condition or to an active control reading mentoring condition.
Children in both groups demonstrated statistically significant improvement in
ADHD symptoms. However, the children in CCPT demonstrated statistically
significant improvement in overall child behavior characteristics, emotional
lability, and anxiety/withdrawn behaviors, typically associated with ADHD.
The authors concluded that CCPT was especially relevant for the comor-
bid symptoms that accompany ADHD characteristics, allowing children to
develop accepting relationships with therapists and to express their feelings
and behaviors in a safe environment. Schottelkorb and Ray (2009) used a
rigorous single-case design to study the effects of CCPT and a person-centered
teacher consultation model on children with ADHD. Of the four participants,
two children demonstrated substantial reduction, and two children dem-
onstrated moderate reduction in ADHD symptoms.
Additional research supports the use of CCPT with sample popula-
tions exhibiting externalizing/disruptive behavioral problems. Muro, Ray,
Schottelkorb, Smith, and Blanco (2006); Packman and Bratton (2003);
Ray (2008); Swan and Ray (2014); Tsai and Ray (2011); and Tyndall-Lind,
Landreth, and Giordano (2001) showed promising results for children who
demonstrated externalized behavioral problems in various settings (i.e., clin-
ics, schools, domestic violence shelter) with specific populations (i.e., children
with learning disabilities, clinically referred children, and traumatized chil-
dren). Muro et al. (2006) found that children who participated in 32 sessions

of play therapy made statistically significant improvements on total behav-
ioral problems and teacher–child relationship stress. Using archival data, Ray
explored the impact of CCPT on parent–child relationship stress. Results
indicated that CCPT had a statistically significant effect on parent–child rela-
tionship stress for children with externalizing behavior problems. Utilizing
a rigorous single case design, Swan and Ray explored the impact of CCPT
with two children labeled with intellectual disabilities. They found that both
children demonstrated substantial decreases in hyperactivity and irritability
behaviors following 15 sessions of CCPT. In their multiple regression analysis
of archival data from a university clinic, Tsai and Ray found that when parents
sought treatment for children due to disruptive family relationship problems,
CCPT demonstrated high levels of effectiveness on decreasing problematic
child behavior. Tyndall-Lind et al. found that child witnesses to domestic
violence experienced statistically significant reductions in externalizing behav-
iors and total problem behaviors following participation in humanistic sibling-
group play therapy.
The following is a case example of working with a child who demonstrates
externalizing problem behaviors. James, a 7-year-old boy, was referred to play
therapy by his teacher for hitting other children, yelling and expressing anger in
class, and having difficulty following directions. James began the play session
by having the dinosaur and the shark wrestle and fight with one another in the
sandbox, knocking large amounts of sand out of the sandbox. The therapist
set a limit on dumping sand from the sandbox, yet James continued to break
the limit. The therapist set the limit again: “James, I know you really want
them to fight hard, but the sand is for staying in the sandbox.” The purpose of
setting limits in this manner was to convey acceptance and empathy toward
James’s feelings of anger and desire to fight, while protecting the playroom
and materials. Angrily, James threw the dinosaur and the shark on the floor.
Then James picked up two swords, handing one to the play therapist, and
engaged the play therapist in a sword fight.
James: I’m going to get you.
Therapist: You’re coming for me. You don’t like it when I say some-
thing is not for doing in here. [James hits his sword against
the therapist’s sword repeatedly.]
James: I’m going to kill you.
Therapist: You really want to get me.
James: Hi-yah!
James swings the sword with great force and hits the therapist’s sword.
The therapist continues to reflect and accept James’s feelings of anger toward
him in order to facilitate James’s self-expression, while establishing limits to
396 ray and jayne

promote James’s capacity to regulate his emotions and behaviors. James hits
the therapist aggressively on the arm with the sword.
Therapist: James, I know you’re really angry with me. But I’m not
for hitting. You can hit my sword or the bop bag. [James
continues to hit the therapist on the arm.]
Therapist: That hurts me and I’m not for hurting. [The therapist expresses
his feelings of pain calmly in order to relate to James in a congru-
ent manner and maintain his level of empathy and unconditional
positive regard. James hits the therapist with more force.]
Therapist: James, I’m not for hurting. You’re super mad at me and want
me to know it. But I’m not for hitting on the arm. You can
hit my sword or you can hit the bop bag and pretend it’s me.
[James moves toward the bop bag and continues to hit it repeat-
edly with the sword.]
Therapist: Even though you’re really mad at me, you chose to hit the
bop bag instead of me. [James fights the bop bag until it falls to
the ground.]
James: I killed it.
Therapist: You defeated it. You feel strong.
Through the therapist’s congruent expression of empathy and accep-
tance, James felt free to express his feelings of anger, resulting in the ability
to regulate his behavior and find appropriate ways to express his aggression.
Internalizing
Internalizing problem behaviors are typically identified as mood dis

orders, more specifically characterized by anxiety, depression, and withdrawn
behaviors. Humanistic child therapy researchers have demonstrated less
interest in this area; hence, fewer studies have been identified that explore
the use of intervention with these types of behaviors. When internalized dis-
orders are used as dependent variables, they appear in conjunction with the
exploration of externalized behaviors. Bayat (2008), Flahive and Ray (2007),
Garza and Bratton (2005), Packman and Bratton (2003), Ray (2008), Ray
et al. (2007), Schumann (2010), Tsai and Ray (2011), and Tyndall-Lind et al.
(2001) all found that internalizing behaviors decreased following participa-
tion in humanistic therapy, most frequently CCPT. Although not specifi-
cally researched, the success of CCPT with internalizing problems can be
theoretically explained through the safety of the therapist–child relation-
ship, wherein a child can express the depth of anxiety or depression while
knowing that the therapist is there to keep the child safe. The child begins to

internalize that sense of safety and acceptance, realizing that the whole of the
child is intrinsically valued and valuable. The internalization of self-worth
allows the child to let go of behaviors or feelings that were harmful to the
child’s self-structure and to release the self-actualizing tendency.
Shen (2002) explored the use of group CCPT to help children who were
at risk for maladjustment following an earthquake. Following 10 sessions of
CCPT, children demonstrated a significant decrease in anxiety and suicide
risk. The author concluded that, when environmental situations, such as an
earthquake, overwhelm the child’s natural tendency for self-actualization
and threaten the child’s self-structure, children may express their confusion
or discomfort through internalized symptoms including anxiety and suicidal
thoughts. CCPT offered an environment where feelings were expressed, iden-
tified, recognized, and accepted by others, relieving children from overwhelm-
ing feelings to focus on coping. Pretorius and Pfeifer (2010) explored the use of
a humanistic art therapy group intervention with 25 girls in South Africa who
had been sexually abused. Using a Solomon four-group design, the authors
found that children in the therapy group improved significantly on depression
and anxiety symptoms when compared with a no-intervention control group.
These two studies support the use of humanistic therapy when children placed
in situations beyond their control have internalized their lack of power.
The following is a case example of working with a child who struggles
with internalizing problems. Sarah, an 8-year-old girl who experienced low
self-esteem and frequent performance anxiety in school, spent her time in
her play session repeatedly setting animal figurines up in straight lines by
descending height on the floor. She often became frustrated, giving up when
they fell over or were not exactly in order. The therapist reflected her need to
have the items perfect, but also looked for opportunities when Sarah allowed
herself more freedom for imperfection.
Therapist: You really want them to be as straight as possible. You like
them to be perfect.
Sarah: [adjusting and readjusting animals to line them up perfectly]
Mmm . . . hmm.
[Sarah accidentally knocked a giraffe over while lining it up, causing
several of the other animals to be scattered out of their straight line.]
Sarah: Uhh. Now it’s ruined.
Therapist: Oh, you’re frustrated you knocked them out of line. They
just weren’t right.
[Sarah proceeded to pick up animals and start lining them up again.]
Therapist: You’re trying again even though it was messed up. It might
be okay if it’s not perfect this time. [The therapist sought to
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reflect what appeared to be Sarah’s experience in the moment.
Sarah continued to place the animals in a line and almost knocked
another one down.]
Sarah: Whoa. That was close. They almost fell over again.
Therapist: You were worried it might happen again. You worry when
you can’t get it right. [Sarah started to move the animals further
apart, spreading them around to keep them from knocking one
another over.]
Therapist: You’re giving them more space so they don’t fall over. You’d
rather they stand up than be in a straight line. It’ll be okay if
they aren’t straight. [Again, the therapist sought to reflect what
appeared to be Sarah’s experience in the moment.]
Sarah: They don’t have to be in a line. They can be anywhere. [shift-
ing attention from lining up animals to searching for other toys]
They’re getting ready for the circus.
Therapist: They don’t have to be perfect to be in the circus. It’s okay to
not be perfect.
Given the freedom to express her anxiety, frustration, and desire for per-
fection within an empathic and trusting relationship with her therapist, Sarah
was able to experience increased self-acceptance and integrate her mistakes
and imperfections into her self-structure. Sarah experienced less anxiety and
became more flexible in her play and more confident in her abilities to accom-
plish tasks and solve problems.
Academic/Language
Academic progress is a historical variable of interest in play therapy

outcome research. As early as 1949, Axline examined the effects of CCPT
on intelligence and reading ability, finding that there were improvements in
both areas following play therapy. However, Axline did not conclude that
play therapy increased the intelligence of children, hypothesizing instead
that play therapy allowed the child to overcome emotional limitations that
hindered expression of intelligence, thereby releasing the child to demon-
strate full potential. Currently, intelligence is considered an innate charac-
teristic that is heavily influenced by context and difficult to capture through
assessment. Yet, the belief that CCPT or other humanistic interventions that
allow the whole of the child to work through emotional barriers within a safe
relationship still resonates as an explanation for how CCPT is effective in the
academic world of the child.
Blanco and Ray (2011), followed by Blanco, Ray, and Holliman (2012),
studied the impact of CCPT on 43 young children identified as academically

at risk. In an experimental study, Blanco and Ray found that children who
participated in 16 sessions of CCPT over 8 weeks showed statistically signifi-
cant improvement in academic achievement over a no-intervention control
group. Blanco et al. continued to follow the intervention group, finding that
children in the original intervention group continued to improve in academic
achievement throughout the year. The authors recommended CCPT as a best
practice to respond to the needs of children who struggle academically. Danger
and Landreth (2005) examined the use of group CCPT with 21 children who
qualified for speech therapy, finding that children increased receptive and
expressive language skills over children in the control condition. Shechtman
and Pastor (2005) conducted a large experimental study with 200 children
diagnosed with a learning disability, discovering that children who partici-
pated in 15 sessions of humanistic group therapy demonstrated improvement
in reading and math over children who received academic assistance or a cog-
nitive behavioral group treatment. The authors further noted that humanistic
group therapy was effective without the use of academic assistance.
Two other studies focused their research on additional characteristics of
children with special learning problems. Packman and Bratton (2003) ran-
domly assigned 24 children diagnosed with learning disabilities and behavioral
problems to a humanistic activity therapy group or a no-intervention control
group. Results revealed that children in the therapy group decreased external-
izing and internalizing problems at a statistically significant level over children
in a control group. Swan and Ray (2014) used a rigorous single case design to
explore CCPT with two children labeled with intellectual disabilities. They
found that both children demonstrated substantial decreases in hyperactivity
and irritability behaviors following 15 sessions of CCPT. These studies pro-
vided support for humanistic interventions to address the behavioral concerns
of children with learning disabilities.
Relationships
The relationships between children and their caregivers, including par-

ents, guardians, and teachers, are of particular interest in humanistic child
interventions. Because relationships are fundamental to the growth and devel-
opment of all people, interventions that use the therapeutic relationship as a
healing factor and work toward healthy relationships outside of therapy are espe-
cially relevant to humanistic child interventions. Several CCPT studies have
focused on parent–child and teacher–child relationships as outcome variables.
Parent–child relationships were explored in Dougherty and Ray’s (2007)
study on the effect of CCPT on such relationships when controlling for the
developmental level of children. Following 24 children referred for counsel-
ing for behavioral problems over 19 to 23 CCPT sessions, Dougherty and Ray
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found that children demonstrated statistically significant decreases in parent–
child relationship stress overall. Ray (2008) examined data over the course of
therapy for 202 children referred for counseling who subsequently received
CCPT. Results indicated that children referred for clinical levels of external-
izing, internalizing, and combined problems demonstrated statistically signifi-
cant improvements in parent–child relationships following participation in
CCPT. The effects increased with the number of sessions, reaching statistical
significance at 11 through 18 sessions and continuing to improve thereafter.
Teacher–child relationships have been an additional focus of CCPT
research. Muro et al. (2006) followed 23 children over 32 sessions of CCPT
in a school year; teachers reported statistically significant improvement in
their relationships with the children over time. Ray (2007) conducted an
experimental study, randomly assigning 93 children to 16 sessions of CCPT,
person-centered teacher consultation, or combined CCPT and teacher con-
sultation. Teachers reported improvement in relationships with children and
improvements in child behavior under all three treatment conditions. To
explore further the methods of CCPT delivery, Ray, Henson, Schottelkorb,
Brown, and Muro (2008) conducted an experimental study with 58 children
assigned to a short-term intensive CCPT condition (16 sessions over 8 weeks)
or to a long-term CCPT condition (16 sessions over 16 weeks). Although
children in both groups demonstrated statistically significant improvement
in teacher–student relationships following CCPT, the short-term condition
resulted in larger effect sizes, indicating greater improvement when compared
to the long-term condition. The authors concluded that short-term, inten-
sive treatment may be more effective due to the provision of more consistent
therapy and to decreased complications with delivery of services due to fewer
disruptions to services, scheduling issues, or premature terminations within
the shorter treatment time frame.
When child relationships are used as variables in research, they are typi-
cally measured by the adult in the relationship. For the previously reviewed
studies, all measures were completed by the teacher or parent. One substantial
limitation of this approach is that the child does not have a voice in the mea-
surement of the relationship. However, the improvement of parent or teacher
attitudes and/or observations indicates that they experienced the child differ-
ently and more positively following participation in humanistic intervention.
Self-Concept/Sense of Competency
A child’s view of self is a logical construct of interest for humanistic

interventions. Positive self-concept and strong sense of competency help
children strive toward developmental tasks and maturity, unleashing the self-
actualizing tendency. However, very few humanistic child studies have

examined self-concept in recent years. Outcomes from studies prior to 2000
were mixed (Bratton & Ray, 2002). Researchers have noted the challenges and
limitations of measuring the construct of self-esteem (Bracken & Lamprecht,
2003; Guindon, 2002). The multilayered dimensions of self-concept and
changes in children’s perceptions of self through the course of their develop-
ment are difficult to assess with given instruments. Mixed results and lack of
reliable assessments for self-concept may contribute to a decrease in studies
exploring the relationship between humanistic intervention and children’s
perception of self. At the same time, a few studies did find a positive impact of
humanistic intervention on self-concept or sense of self.
Baggerly (2004) measured the self-concept of 42 children in a homeless
shelter who participated in nine to 12 individual CCPT sessions. She found
that these children demonstrated significant improvement in self-concept,
sense of significance, competence, and self-esteem related to depression and
anxiety. Scott, Burlingame, Starling, Porter, and Lilly (2003) found that
26 children referred for sexual abuse indicated an increased sense of compe-
tency after seven to 13 sessions of CCPT. Tyndall-Lind et al. (2001) com-
pared 32 children assigned to group CCPT or to a no-intervention control
group, finding that children who participated in CCPT reported a signifi-
cant improvement in self-esteem. Baggerly concluded that improvement in
the sense of competence could be a result of common play therapy practices
utilized to support the child’s self-responsibility, encourage the child’s effort
and capabilities, and promote the child’s self-esteem, whereas Tyndall-Lind
et al. determined that when children experienced being valued, respected,
and honored within a nurturing context, they changed their self-perceptions.
Recent Topics of Focus
Exposure to traumatic events is common among U.S. children and may

result in deleterious effects, such as altered brain functioning, depression,
anxiety, and risk-taking behaviors (Wethington et al., 2008). Although cog-
nitive behavioral treatments are common for children struggling with trauma,
humanistic interventions have demonstrated promising preliminary results.
Following a severe earthquake in Taiwan, Shen (2002) found that children
who participated in group CCPT demonstrated decreases in anxiety and sui-
cide risk. Tyndall-Lind et al. (2001) studied the impact of group CCPT on
children in a domestic violence shelter, finding that they demonstrated sig-
nificant reductions in anxiety, depression, and externalizing and internalizing
behavior problems. Scott et al. (2003) found that children referred to a clinic
for sexual abuse who participated in CCPT experienced increased confidence
in their abilities and self-esteem overall. Finally, Schottelkorb, Doumas, and
Garcia (2012) compared 26 refugee children randomly assigned to CCPT or
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to trauma-focused cognitive behavioral therapy (TF-CBT). They found that
both CCPT and TF-CBT were statistically significant in reducing trauma
symptoms, noting that the effectiveness of CCPT was found to be equal to
the widely accepted evidence-based treatment of TF-CBT. Taken together,
these studies indicate that CCPT demonstrates promising evidence as a via-
ble and effective intervention for children who have experienced trauma.
Consideration of global and individual child development to inform
therapeutic practice allows the humanistic researcher to focus on the whole
child from an affirmative perspective. Instead of attending to perceived deficits
of attitudes or behaviors, a developmental perspective provides a lens to view
the child as a person moving through natural phases of life. A few researchers
have preferred the use of development as an outcome construct, examining
the relationship between CCPT and developmental change. Baggerly and
Jenkins (2009) followed the development of 36 homeless children over 11
to 25 sessions of CCPT. Children in CCPT demonstrated statistically sig-
nificant improvement on the developmental characteristic of internalizing
control, including being emotionally secure, accepting constraints, accom-
modating others, responding constructively to others, and maintaining inter-
nalized standards. In an experimental single-case design, Garofano-Brown
(2010) followed three young children from baseline through eight sessions of
CCPT and a follow-up phase. She found that the children increased in mea-
sured developmental age, reduced problematic behaviors related to develop-
mental delays, and increased developmentally appropriate behaviors. Finally,
Dougherty and Ray (2007) found developmental differences on parent–child
relationship characteristics in children who participated in CCPT. Although
children overall demonstrated significant change in parent–child relation-
ship stress, the authors reported that children in a concrete operations group
experienced more improvement in relationship stress than did children in
the preoperational group. All of these research studies explored development
in a qualitatively different way, indicating the intent to capture a greater
understanding of children from a developmental perspective.
In reviewing studies conducted before and since 2000, humanistic ther-
apies, specifically CCPT, continue to affirm the effectiveness of interventions
with a diverse number of outcome variables across diverse populations. Ray,
Stulmaker, Lee, and Silverman (2013) hypothesized that the construct of
impairment, which may be more closely aligned with humanistic therapy
than is commonly thought, would be an outcome variable of interest for
CCPT. Similar to a developmental perspective, conceptualizing children
from an impairment model offers a more holistic lens for humanistic research.
Because of its broad inclusion of child functioning—including a diminished
ability to perform at developmentally expected levels, resulting in difficul-
ties in daily life activities such as dysfunction or an absence of adaptation

in social, emotional, psychological, or occupational/academic domains—an
impairment framework promotes a more complete picture of child function-
ing (Fabiano & Pelham, 2009). Conducting an experimental pilot study with
37 children assigned to CCPT or no-intervention, Ray et al. found that chil-
dren who participated in 12 to 16 sessions of CCPT demonstrated decreased
levels of impairment, with a medium effect size, when compared to the no-
intervention control group children, who showed consistent or increased
levels of impairment. Findings from this study indicate a promising outcome
variable that closely aligns with the full functionality of the child, a more
philosophically consistent focus for humanistic research than more limiting
outcomes such as diagnoses or disorders.
Recent research on the child–therapist alliance and interpersonal neuro
biology supports the humanistic approach to play therapy with children. Shirk
and Karver (2011) conducted a meta-analysis on therapeutic alliance in child
psychotherapy. They found that approaching children in a formal, didactic
manner as well as pushing and praising were counterproductive to forming
a child–therapist alliance. The authors concluded that a less directive and
less task-focused approach to therapy is critical to the beginning of therapy,
suggesting that person-centered strategies may be more effective for alliance
formation. Shirk and Karver noted the importance of flexibility, collaboration,
and understanding the child’s concerns as therapist mediators in a positive
therapist–child alliance.
The importance of the therapeutic relationship has been further sup-
ported in the work of Siegel (2006) and Badenoch (2008), who connected
research in neurobiology to implications for therapy. Siegel proposed that
strong correlations exist among an empathic relationship, coherent mind, and
integrated brain. Emphasizing the importance of brain integration and knowl-
edge of mirror neurons, Siegel explained that being empathic is more than just
a technique to help clients feel better, as it “may create a new state of neural
activation with a coherence in the moment that improves the capacity for
self-regulation” (p. 255). Resonance between therapist and child allows the
child, as well as the therapist, to build new neural circuits that create pathways
for neurochemicals that help regulate the child’s system (Badenoch, 2008).
The new neural pathways from limbic circuits to middle prefrontal regions are
strengthened, leaving a stronger ability to self-regulate. As children are val-
ued, accepted, and allowed to lead their play experiences, their brains respond
by releasing opioids, supporting well-being and connection.
Summary of Current Review
Following a review of the 32 humanistic child studies conducted since

2000, several observable conclusions are evident from the research. Overall,
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as Rogers (1961) once said, “the facts are friendly” (p. 25). Results from
the reviewed studies indicate that humanistic child intervention is effec-
tive across a broad range of children and presenting problems. Some stud-
ies reveal stronger results than others, yet most published humanistic child
studies demonstrate some favorable findings in support of intervention. Over
time, it appears that humanistic outcome research has increased in rigor regard-
ing experimental design. Seventeen studies were conducted according to strict
experimental guidelines, using random assignment, control/comparison groups,
detailed descriptions of treatment or treatment protocols, fidelity checks,
and appropriate data analysis and interpretation. This adherence to accepted
guidelines in the field elevates the status and findings of results. The recent
addition of studies that used experimental single-case design also marks a
positive evolution of humanistic research, particularly due to the integrated
quantitative and qualitative nature of this type of research design and its
accepted status in the evidence-based movement.
Humanistic child studies appear to be almost exclusively rooted in play
therapy, more specifically CCPT. A search for child intervention research
resulted in hundreds of citations, mostly interventions that were cognitively
or behaviorally based. Humanistic child therapies other than CCPT were
represented in the literature but most frequently as practice or theory articles.
This finding is consistent with Elliott et al.’s (2013) observation of a revival
of person-centered therapy research with adults as a recent development.
Although CCPT continues to produce and demonstrate effective results
across studies, humanistic intervention would benefit from an increased num-
ber of studies based in other philosophically aligned orientations.
Humanistic research is concentrating on outcome variables that appear
to be relevant to current treatment intervention research. Dependent vari-
ables such as trauma, disruptive behaviors, and academic progress are fre-
quently explored in contemporary child research. These have also been
variables of interest in play therapy and humanistic treatment research.
However, the frequency of research in traditional areas of interest such
as social skills and adjustment, medical treatment, and self-concept has
decreased in the past decade. For example, Farahzadi, Bahramabadi, and
Mohammadifar (2011) conducted the only study that explored the impact
of play therapy on social phobia, whereas Jones and Landreth (2002) carried
out the only study that explored the effects of play therapy on children with
a medical condition. Traditionally (see Bratton & Ray, 2002), play therapy
studies on social adjustment and medical conditions have been prevalent in
the literature. Both Farahzadi et al. and Jones and Landreth found positive
effects from Gestalt play therapy and CCPT, respectively, on their outcome
variables of interest. The reason for the decrease of research in these areas is
difficult to discern. One explanation might be the concentrated number of

studies dedicated to disruptive behaviors, a common area of focus in all child
intervention research.
Overall, humanistic child therapies demonstrate their greatest strength
as being viable, practical, and effective in real-world settings. Unlike many
child intervention efficacy studies conducted in clinic laboratories and con-
trolled university settings, humanistic studies have been conducted in settings
where children can be found every day. Of the 32 studies, settings included
a homeless shelter, a domestic violence shelter, a sexual abuse center, a dia-
betic camp, and an orphanage. Remarkably, 22 of the studies were conducted
in mostly low-income, highly diverse schools, indicating that humanistic
interventions are effective with children in their natural settings. Although
generally accepted evidence-based, typically cognitive–behavioral, interven-
tions struggle to result in strong positive findings in real-world settings with
real-world clients (Weisz, Ugueto, Cheron, & Herren, 2013), humanistic
studies are grounded in standard treatment settings. In contrast to most con-
trolled experimental studies conducted with cognitive-behavioral interven-
tions, humanistic studies have included ethnically diverse participants. Garza
and Bratton (2005) conducted their study solely with Latino/a participants,
whereas several other studies included a balanced percentage of Latino/a,
African American, and Caucasian participants. The substantial number of
studies conducted in the real-world setting of schools most likely accounts
for the diversity of participants. In addition to diversity within studies con-
ducted in the United States, those conducted outside the United States indi-
cate that humanistic intervention is effective across cultures. Bayat (2008)
and Farahzadi et al. (2011) in Iran, Pretorius and Pfeifer (2010) in South
Africa, Shechtman and Pastor (2005) in Israel, and Shen (2002) in Taiwan
have demonstrated cross-cultural positive effects of humanistic intervention.
Additionally, a few studies from different countries, which were identified but
were unavailable in English, could not be included in this review because of
lack of details in the abstract.
A final observation regarding the relationship between humanistic
child intervention and real-world use involves the number of sessions nec-
essary for demonstrable effects. Although humanistic intervention is often
characterized as lengthy, the number of sessions typically used in research
studies since 2000 was fewer than might be expected—a mean of 16 sessions
across studies. Often, sessions were delivered in an intensive manner of two
30-min sessions per week, resulting in 8 weeks or less for effective results. A
notable number of studies found positive results following eight to 10 sessions,
indicating that humanistic child intervention, most frequently delivered as
CCPT, is competitive as a short-term intervention for children’s presenting
problems. However, it should be recognized that children with complicated
issues and contexts benefit from lengthier therapeutic relationships in which
406 ray and jayne

the therapist is able to more fully understand the child, provide numerous
experiences of empathic understanding and unconditional positive regard,
and allow time for the child to integrate such experiences.
CASE EXAMPLE
The case of Rachel, who was 6 years old when she was referred for play
therapy, is provided to demonstrate how principles are concretely enacted
in CCPT. Rachel’s mother had been absent from her life since Rachel was
2 years of age because of alcohol addiction and domestic violence. Before
being separated from her mother, Rachel witnessed her mother being physi-
cally aggressive toward her father and being arrested and escorted to jail by
police officers. At the time Rachel began play therapy, she lived with her
father and paternal grandparents. Her father worked and attended school full-
time. Rachel frequently wet the bed at night and had intense nightmares sev-
eral times a week. She feared physical separation from her father, continuously
asked about her mother’s absence, and was difficult to soothe. Her father and
teachers reported that Rachel was very obedient and helpful at home and at
school, but was overly concerned about making mistakes and being punished.
Sessions were held in a playroom in a clinic setting. The playroom,
which included hundreds of toys on shelves, was organized according to
nurturing, aggressive, real-life, and expressive categories. The first session,
Rachel was nervous about coming to the playroom with the therapist and
concerned about separating from her father. She clung tightly to him.
Therapist: Rachel, you feel scared to come to the playroom. You’re
nervous about leaving your dad.
Rachel: [clinging tighter to dad and facing away from therapist]
Therapist: [bending down to be at the same height as the child] You’re not
too sure about all this. You would rather stay with your dad.
[Rachel’s father reassured her that she would be okay and that he
would be waiting for her after the play session.]
Rachel: [looking back and forth between her dad and the playroom]
Therapist: You’re scared, but you think maybe it would be okay since
your dad said he’ll be waiting for you.
[Rachel let go of her dad’s hand and walked into the playroom.]
The play therapist reflected Rachel’s feelings, acknowledging her desire
to stay with her father, to communicate understanding and acceptance of
Rachel’s experience. The play therapist aimed to support sensitively Rachel’s

process of separating from her father and entering the playroom in a manner
that communicated trust in the child and the child’s self-direction.
As sessions continued, Rachel made little eye contact with the thera-
pist and often played across the room, limiting her physical proximity to the
therapist. Rachel cautiously explored the room, picked up toys, and played
with them in different ways. The play therapist reflected her actions and
empathically matched Rachel’s affect, tone, and physical movement to com-
municate that she was interested in Rachel and her world.
As Rachel’s sense of safety and trust in the therapist developed and
she was more receptive to the therapist’s acceptance and empathy, Rachel
became more expressive and verbal in her play. Frequently, Rachel would
move toward the therapist or initiate contact by handing the therapist a toy,
but would stop midstride and change her play behavior. Typically, in play
therapy, children will choose to use the play materials to symbolically express
themselves as they work through issues that are meaningful to them.
Rachel: [picking up a dress and putting it over her head] Let’s play dress-up.
Therapist: You want us to get dressed up together.
Rachel: You can be the princess. [picking up crown and carrying it
toward therapist to put on therapist’s head and then suddenly
turning away from therapist]
Therapist: Sometimes you want to be close to me, but then you feel
scared. You’re not sure what to do.
Rachel: You can wear whatever you want.
Therapist: I can choose anything.
Rachel: [picking up a feather boa and walking toward therapist] You can
wear this one. It’s fancy. [places boa around therapist’s neck]
Therapist: You wanted me to wear it and decided it was okay to put it
on me.
In this interaction, the therapist responded to the child’s internal con-
flict, accepting Rachel’s anxiety and fear in the relationship and her conflict-
ing desires to be near the therapist and to keep her distance. As sessions with
Rachel continued, she began to play with the baby doll and use the medical
kit to take care of the baby. Rachel would have the play therapist be the
baby’s mother and bring the baby to the doctor.
Rachel: This is your baby, and she’s very sick.
Therapist: Mmmm. She’s not feeling well.
Rachel: [listening to baby doll’s heart with stethoscope] Her heart sounds
bumpy.
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Therapist: It doesn’t sound right.
Rachel: [taking baby’s temperature with thermometer] She’s a hundred
and . . . she’s really high.
Therapist: My baby is really sick.
Rachel: [filling baby bottle with sand] And this is her medicine. She’s
got to take it every day. Don’t forget.
Therapist: It’s really important that the baby gets her medicine.
Rachel: [picking up baby and laying her in the sandbox] But you forgot to
give it to her and she got sicker. Now she’s in the hospital.
Therapist: I didn’t take care of her the way I was supposed to, and now
she’s really sick.
Rachel: Now she might die.
Therapist: You’re worried about her. She may not be okay.
Rachel: She’s very sick because you didn’t give her the medicine.
Now I have to do it. [giving baby bottle]
Therapist: You have to take care of her because I didn’t do it. You want
to protect her.
Rachel: [picking up the play phone] I’m going to call the police, and
they are going to come get you. [talking in phone] Yes, you
need to come get her. She didn’t give the baby her medicine.
[talking to therapist] They’re on their way.
Therapist: Now the police are coming to arrest me. I’m in big trouble
because I didn’t take care of the baby.
Rachel: You’re in big trouble.
Therapist: You’re mad that I didn’t take care of her. You want me to be
punished.
Theoretically, the play therapist’s empathy and acceptance of Rachel’s
experience and her need to separate and punish the play therapist as the
baby’s mother allowed Rachel to express her desire to be nurtured and pro-
tected and her feelings of anger and sadness toward her mother.
Rachel: They’re gonna lock you up and take you to jail.
Therapist: I’m going to be arrested. I did something really bad.
Rachel: They’re here. [putting handcuffs on therapist] You’re locked up
and can never get out.
Therapist: I’m going to be locked up forever and ever.
Rachel: You won’t see your baby again.

Therapist: My baby and I can’t be together anymore. You’re sad about
that. You wish mom and baby could be together.
Rachel: [wrapping rope around therapist’s arms] You’re never getting out.
Therapist: You locked me up tight. I’m stuck here forever. Away from
my baby.
As the session continued, the play therapist moved in and out of Rachel’s
world, expressing the empathy she was feeling, mixed with her own feelings
of sadness and pain at being placed in such a painful role in Rachel’s play.
The empathy involved in this session was very painful for the play therapist.
Being open to taking on Rachel’s feelings of helplessness, abandonment, and
loss in this situation was difficult but necessary to understand the kind of pain
she was in on a daily basis. Experiencing her level of pain helped the play
therapist to be in full contact with her and move around in her world, helping
to unleash her actualizing tendency that would allow her to survive, possibly
thrive, through her circumstances and to integrate the reality and trauma of
being separated from her mother into her self-structure. The play therapist
trusted Rachel’s process and ability to resolve her conflicting feelings toward
her mother. Although the play therapist struggled with her own desire to
express care and nurture Rachel in sessions, she trusted Rachel’s capacity to
find a way to express and meet her needs for connection and nurturing in
relationships with others when she was ready.
Rachel: [opening handcuffs and unwrapping rope from therapist] Pretend
I let you out and now we’re going to work.
Therapist: Oh. You freed me and now we need to go to work together.
You’re happy.
Rachel: Pretend I’m your daughter and you’re the mom. And you’re
going to work and I’m going to school. [filling purse with toys]
For several sessions, Rachel’s play continued to revolve around her
relationship with her mother and her experience of abandonment. Rachel
directed the play therapist to be increasingly more nurturing toward the baby
doll and over time discontinued the separation of mother and child from one
another. Rachel’s play became more collaborative, and she often developed
elaborate, noncompetitive games for her and the play therapist to play and
win together. Rachel’s father reported that she experienced fewer nightmares
and decreased bed wetting at night. She also experienced less anxiety when
she separated from her father and was able to stay with her grandparents for
a week without any behavioral problems while he was traveling for work.
Theoretically, Rachel’s experience with CCPT was enhanced by her
relationship with the therapist. The initial sessions appeared to be used to
build her trust in the therapist to fully reveal her deepest fears. The therapist’s
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empathy and belief in Rachel’s ability to direct her process, as well as Rachel’s
acceptance of the conditions provided by the therapist, led to her ability to
integrate her experiences and see herself as valued by another. Rachel’s expe-
rience of being supported through her experience of trauma allowed her to
know that she was capable of surviving this devastating loss. The relationship
between therapist and child unleashed Rachel’s self-actualizing tendency to
thrive through the chaos and disruption of her childhood.
A secondary benefit of experiencing strong empathic relationships with
clients is the ability to advocate for them with other caretakers. For example,
the play therapist consulted with Rachel’s father on a regular basis. The play
therapist said to her father,
She seems to be extremely concerned with being separated from her
mother and about being taken care of and protected. It makes sense to
me that she has difficulty sleeping and feels anxious when she is away
from you because of her confusion about her mother and her fear that
she may lose you as well.
The play therapist’s ability to express Rachel’s world to the father helped him
be more understanding (possibly empathic) of her behavioral problems.
CONCLUSION
In reviewing humanistic child research, there are some key implications

for practice:
77 Humanistic child interventions value the person of the child and
the child’s worldview, evident through the consensus of a delivery
system that uses play and expressive arts. Humanistic therapists
use play or expressive arts therapy to speak the language of the
child.
77 Humanistic child interventions are supported by recent devel-
opments in research on the therapist–child alliance, suggest-
ing that that alliance is strengthened when therapists initiate
relationships where children lead while the therapist is flexible,
collaborative, and accepting.
77 Humanistic child interventions are supported by recent devel-
opments in neurobiology indicating that strong empathic rela-
tionships lead to integration of the brain and regulations of its
systems.
77 Humanistic child interventions are heavily represented by
CCPT, which has increased in research rigor and quality over
the last two decades and has resulted in positive outcomes

related to disruptive behavioral problems, internalizing prob-
lems, academic progress, child–adult relationships, self-concept,
trauma, development, and functional impairment.
77 Humanistic child interventions offer a viable and practical
option for real-world settings. Intervention has been tested in
natural settings, where therapists see children who have com-
plex and diverse backgrounds. Length of treatment also appears
to be aligned with other child interventions.
77 Humanistic child interventions would benefit from continued
rigorous examination of outcome variables of concern to the
general public. For example, few studies examined specific prob-
lems such as depression or anxiety in children.
77 Humanistic child interventions would benefit from examina-
tion of mediating and moderating factors that affect outcome.
Although it appears that humanistic interventions are effective,
there are no recent outcome studies exploring the role of specific
relational variables such as therapist congruence, empathy, or
acceptance in treatment outcome for children.
Research on humanistic interventions with children has experienced a
resurgence in the last decade, increasing in frequency and quality. Outcomes
are favorable. The number of humanistic approaches with children is limited
and most frequently delivered through the modality of play therapy, specifi-
cally CCPT in most cases. There appears to be a consensus in the literature
that humanistic therapies for children are almost exclusively delivered through
play or expressive arts modalities, recognizing the developmental language of
children. Positive outcome in play therapy now spans over seven decades, ren-
dering it possibly the longest researched psychotherapy modality for children.
Meta-analyses, developments in neurobiology, and individual studies support
the principles embraced by humanistic therapists, including the primacy of
the therapist–child relationship as the healing factor in therapy.
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V
Therapeutic Issues
and Applications
13
THE GOOD THERAPIST: EVIDENCE
REGARDING THE THERAPIST’S
CONTRIBUTION TO PSYCHOTHERAPY
KEVIN KEENAN AND SHAWN RUBIN
What is a good therapist? Since Rogers (1957), the humanistic psycho-

therapies have had a lot to say about what constitutes a good therapist, per-
haps more so than any other therapeutic orientation. Rogers’s grounding in
research and practice led him to conclude that it is the therapist’s personal
qualities and personal manner of relating that are central to the process of
personal growth in therapy. These early relational principles have formed the
bedrock of the humanistic psychotherapies. It is the evidence for these and
other relational principles that addresses the question of what constitutes a
good therapist and by extension what constitutes good therapy.
Although there are excellent descriptive approaches to articulating the
qualities of a good therapist (Duncan, 2014; Kottler & Carlson, 2014), the
approach we take here is based on the evidence from the research literature.
In the current review, we begin by addressing the question of how much
http://dx.doi.org/10.1037/14775-014
S. Rubin (Editors)
421
therapists actually contribute to client improvement. Then, the particular
attributes of therapists that account for their helpfulness are examined. Note
that in this chapter, we deal with the effects of the personal and professional
qualities of therapists rather than with therapists’ techniques. Although
special attention is given to the therapist’s contribution to outcome in the
humanistic psychotherapies, in this review we examine the currents that run
throughout the entire research literature that have bearing on the person of
the therapist in therapy.
Throughout the chapter, the focus is on major reviews and meta-analyses
whenever possible, as the sheer number of studies bearing on therapist factors
precludes giving attention to individual studies unless they are of landmark
status. In sum, an effort is made to provide the reader with the best available
research evidence pertaining to therapist factors that contribute to effective
psychotherapy.
RESEARCH PRIOR TO 2000
How Effective Are Therapists?
In his review of the early psychotherapy outcome literature, Bergin

(1971) concluded that therapy had a moderately positive average effect and
opined that this effect was the result of a combination of some clients making
strong therapeutic improvements with good therapists, whereas other clients
deteriorated with poor ones. In a later effort to speak to the question of thera-
pists’ effectiveness, Luborsky et al. (1986) reexamined the data from four large
scale studies and concluded that “the frequency and size of therapist effects
generally overshadowed any difference between different forms of treatment”
(pp. 508–509) and thus asserted that therapist qualities mattered more to
outcome than therapist theoretically driven techniques.
Using a more sophisticated statistical analysis, Crits-Christoph et al.
(1991) reanalyzed the results of 15 studies and determined that therapists
were responsible for 9% of treatment outcome. Although this may seem like
a small number, it is a moderate effect size according to statistical conven-
tions (see Wampold, 2001, pp. 51–53, for a description and comparison of
effect sizes common in psychotherapy research). For comparison purposes,
this effect size for therapists is nearly twice as large as the average effect size
found in all studies of antidepressants approved by the U.S. Food and Drug
Administration (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008) and
is equivalent to a success rate of 65%.
Wampold (2001) examined the results of the preceding reviews as
well as several additional studies from the 1990s and concluded that overall,
422 keenan and rubin

therapists account for between 6% and 9% of outcome variance. Wampold
also noted that the therapeutic effect due to different treatments is about
1%, thus providing a foundation for a critique of much of the psychotherapy
research of the preceding two decades that had attempted to identify superior
treatment techniques at the expense of ignoring the role of the therapist.
The Therapeutic Effectiveness of Specific Therapist Qualities
Therapists are generally effective, and some are more effective than others.
However, what about them is effective in helping clients make treatment gains?
Rogers’s (1957) articulation of the therapist’s facilitative conditions—empathy,
genuineness, and unconditional positive regard—have become the bedrock of
the humanistic psychotherapies and have become so widely accepted that they
have been assimilated into the culture of psychotherapy in general.
In their review of therapist relational variables in the first edition of this
volume, Asay and Lambert (2002) concluded that by the year 2000, “it would
probably be safe to say that there is general agreement between research-
ers and clinicians alike that therapist facilitative skills are essential to the
formation of positive therapeutic relationships and contribute significantly
to therapeutic outcome” (p. 537). Among the key findings of their review
is the conclusion that client ratings of therapist variables are more predic-
tive of outcome than clinician and objective raters. Asay and Lambert noted
that there are still unresolved issues regarding how the facilitative conditions
are defined, measured, and distinguished from one another because empathy,
positive regard, and congruence are highly correlated. Therefore, in their
review, they did not report the findings for each of the facilitative conditions
separately.
Other reviewers have maintained the distinction between the facil
itative conditions. For instance, a series of reviews commissioned by the
American Psychological Association Division of Psychotherapy Task Force
on Empirically Supported Therapy Relationships (Norcross, 2002) examined
the literature before 2000 on a number of relational variables. Those reviews
pertaining to each of the facilitative conditions are briefly described later. The
review of therapist empathy is done in more detail to illustrate the methods
used in meta-analyses that have become a standard for major reviews in recent
years. Prior to the advent of meta-analyses, reviewers used their judgment to
combine the results across studies. Different reviewers often arrived at dif-
ferent conclusions for the same group of studies (e.g., Bergin, 1971; Parloff,
Waskow, & Wolfe, 1978; Truax & Mitchell, 1971). To remedy this situation,
some reviewers presented tables indicating the number of studies that sup-
ported the hypothesis being reviewed. This method was used in the reviews
regarding congruence and positive regard that follow. These sorts of reviews
the good therapist 423

summarize their findings as box scores. For instance, 34% of the results might
support a hypothesis, 65% might be nonsignificant, and 1% might be oppo-
site to prediction. However, there is no consensus in how to interpret these
box scores. In contrast, meta-analyses offer the advantage of systematically
computing and interpreting the results across many studies.
Empathy
Bohart, Elliott, Greenberg, and Watson (2002) conducted a meta-analysis
of 47 studies involving 3,026 clients published between 1971 and 2000 relat-
ing empathy with therapy outcome. For each study, the correlation between
empathy ratings and outcome measures was computed. These coefficients
were combined into an average weighted correlation to take into account
each sample’s size. The overall results across all measures in all studies showed
a medium effect size (r = .32, equivalent to 9% of the outcome variance).
This effect size indicates that empathy has a moderately strong influence
on therapeutic outcome across a variety of measures, therapies, populations
and settings. Bohart et al. found some surprising results from their secondary
analyses. Contrary to expectation, theoretical orientation had no influence
on the importance of empathy for therapeutic outcome. Therapist empa-
thy is important for both humanistic and nonhumanistic therapies (e.g.,
cognitive behavior therapy [CBT]). Additionally, it was found that experi-
ence level moderated the empathy–outcome relationship, with empathy
being more important to outcome for less experienced therapists relative
to more experienced therapists. Bohart et al. surmised that more experi-
enced therapists might have a wider variety of resources available to help
clients, and hence empathy alone would not be of such central importance
for them.
Positive Regard
There have been two large systematic reviews of the relationship between
positive regard and client outcome in the literature prior to 2000. Orlinsky,
Grawe, and Parks (1994) reviewed 25 studies published between 1979 and
1991, and Farber and Lane (2002) reviewed eight studies published between
1992 and 2000 that were not included in Orlinsky et al.’s review. Both
studies reported the results in terms of box score. Overall, 55% of the results
were positive, 42% were nonsignificant, and 2% were opposite to prediction.
Orlinsky et al. suggested that the variability in the relationship between posi-
tive regard and outcome is due to variability in research conditions such as
the different measurers of positive regard. Farber and Lane noted that signifi-
cant results were much more likely when findings were based on the evalua-
tions of clients as opposed to objective raters.

Congruence
With regard to therapist congruence, Klein, Kolden, Michels, and
Chisholm-Stockard (2002) completed a box-score review of 77 results from
20 studies conducted between 1971 and 2000. They found that 34% of the
results were positive, 1% were negative, and 65% were failed to achieve signifi-
cance. Although generally positive, these findings are weaker than the findings
for empathy and positive regard. Klein et al. concluded that these “mixed”
findings suggest that congruence may be an important component to a more
complex conception of the therapeutic relationship. For instance, it may
exert its influence on outcome indirectly through its effect on the therapeutic
alliance.
The Client–Therapist Relationship

Although the humanistic psychotherapies have emphasized the client–
therapist relationship for more than half a century (Cain, 2002), the opera-
tional definition of the client–therapist relationship has not evolved from the
necessary and sufficient conditions for personality change postulated by Rogers
(1957). Asay and Lambert (2002) noted that the therapist facilitative condi-
tions are thought to make an essential contribution to the client–therapist
relationship and draw upon the conceptualization of the therapeutic alliance to
round out their view of therapist relational skills. The most widely used concep-
tualization of alliance, and one that is entirely compatible with the humanistic
point of view, was developed by Bordin (1979) and entails three components:
consensus on goals; collaboration on therapy tasks; and a positive, open, and
warm relationship between client and therapist. From this perspective, client
and therapist may have different perspectives on goals (e.g., symptom relief vs.
personal growth) and how these goals can be achieved (e.g., “Hey, doc, can you
give me some tools so I can handle things better?”). It is the negotiation of these
goals and tasks through a collaborative process, aided or burdened by the qual-
ity of their relationship, that determines the quality of the alliance between the
therapist and client. Stated somewhat differently, from the humanistic vantage
point, the therapist alone does not build the alliance, but rather the client
and therapist together—through their collaborative work—are involved in an
ongoing process of co-creating the alliance.
Despite both the therapist’s and client’s efforts to make therapy work,
strains and breaks in the therapeutic relationship occur. The term therapeu-
tic rupture has come to refer to both minor strains and major breaks in the
therapeutic alliance (Safran, Muran, Samstag, & Stevens, 2002). Safran et al.
(2002) reported that clients experience alliance ruptures in 11% to 38% of
their sessions. Research suggests that failure to address a rupture is likely to
lead to negative outcomes, whereas rupture resolution marks effective therapy

(Bordin, 1979; Safran, Crocker, McMain, & Murray, 1990; Safran, Muran, &
Samstag, 1994). Additionally, there is evidence that the absence of strains
between therapist and client may indicate that either the therapist or the
client is playing it too safe, is ignoring tensions, or is unwilling to explore
difficult issues (Safran et al., 1990, 1994).
Because clients often do not communicate negative reactions about the
therapist to the therapist (Hill, Nutt-Williams, Heaton, Thompson, & Rhodes,
1996), it is important for the therapist to be attentive to possible indicators of
relational distress (e.g., changes in client engagement, hesitation in speech,
coolness) and to maintain an interest in, and a nondefensive reaction to, any
negative reactions from the client, even subtle ones.
Safran et al. (2002) reviewed the alliance rupture literature and found
18 studies published between 1990 and 2000. Some of the studies in their
review examined the issue of rupture detection and indicated that clients
in general are reluctant to share their negative experiences in therapy with
their therapist. Whereas some clients may confront the therapist with their
dissatisfaction, many may withdraw emotionally or relationally. Results indi-
cated that clients reported that rupture experiences occurred in 19% of ses-
sions, and clients’ indication of ruptures were more predictive of unilateral
termination or negative outcome than therapists’ estimations. Another group
of the studies in Safran et al.’s review examined repair efforts with some star-
tling results. When cognitive and psychodynamic therapists attempted to
repair ruptures by rigidly renewing their adherence to their preferred therapy
orientation (focus on distorted cognitions and transference interpretations,
respectively), the results were therapeutic disaster. Furthermore, when thera-
pists did address ruptures with a genuine concern for the client’s experience,
therapeutic outcomes were even more positive than those who experienced
no rupture at all. These findings indicate that it is not the rupture per se that
is potentially damaging to treatment but rather whether it is appropriately
acknowledged and addressed.
RESEARCH REGARDING THERAPIST

EFFECTIVENESS AFTER 2000
Currently, most therapists have embraced the central features of human-

istic psychotherapy, although only one third think of themselves as humanis-
tic. A survey of more than 2,000 therapists (Cook, Biyanova, Elhai, Schnurr,
& Coyne, 2010) found that 79% of therapists identified themselves as using a
CBT model, whereas only 31% reported using a humanistic model. However,
when these predominantly CBT-oriented therapists were asked to indicate
their specific practices, the top five practices—each endorsed by 90% or more

of the practitioners—were all clearly humanistic and based on the core
facilitative conditions. In contrast, fewer than 50% of this same group of
therapists endorsed any of the practices routinely associated with CBT
(e.g., challenging irrational thoughts, cognitive restructuring, assigning
homework).
The Overall Effectiveness of Therapists
The most recent evidence of the overall effectiveness of the therapist on

outcome can be found in Baldwin and Imel’s (2013) meta-analysis involv-
ing 46 studies with 1,281 therapists who saw 14,519 clients in a variety of
psychotherapies. Across all studies, the therapist accounted for 5% of the
variance, a small to medium effect size, equivalent to an r of .21. When the
results are analyzed separately for naturalistic studies in which therapist vari-
ability in style is not tightly controlled with such methods as treatment
manuals that reduce therapist variability, the variance due to therapists was
7%, a medium effect size (equivalent to an r of .27). In contrast, results from
controlled studies that minimize therapist variability show that the therapist
still accounts for 3% of the variance, a small but significant effect (equivalent
to an r of .16).
Baldwin and Imel’s (2013) review has several important implications.
First, these overall results are very similar to estimates reported in the earlier
reviews cited in this chapter. Second, even when researchers try their best to
remove the effects of the therapist from therapy, a small but significant ther-
apist effect remains. Third, differences between therapist quality are most
evident at the extremes of therapist effectiveness. For instance, in one meta-
analysis involving 71 therapists who on average saw 92 clients, the clients
of the most effective therapists had twice the improvement rate and half the
deterioration rate of the clients seen by the least effective therapists (Okiishi
et al., 2006). Fourth, there is wide variability in the outcomes among the
caseloads of all therapists. Thus, the best outcomes among the worst thera-
pists are often as good as the worst outcomes among the best therapists. In
light of the variability within and between all therapists, there is consider-
able room for improvement, even among the best therapists. Furthermore,
therapists are often inaccurate judges of just how good they are, usually over-
estimating their effectiveness (Walfish, McAlister, O’Donnell, & Lambert,
2012). Additionally, as therapists become more experienced postlicensure,
they do not generally become more effective. However, they do develop
greater confidence in their effectiveness (Tracey, Wampold, Lichtenberg,
& Goodyear, 2014). In light of these findings, therapists are advised to
develop systematic efforts at self-assessment and improvement throughout
their careers.

Therapist Characteristics Associated With Better Outcomes
As we have seen in the earlier literature, several factors account for

better outcomes across different therapists—empathy, positive regard, and
congruence along with having a collaborative therapeutic alliance all have
been moderately predictive of client improvement. In what is to follow, we
review the most recent research on attributes of the therapist that are most
strongly related to therapy outcome.
Empathy
In the most recent meta-analysis of empathy, Elliott, Bohart, Watson, and
Greenberg (2011) examined 59 studies with 224 separate effects (studies with
more than one measure of empathy have more than one effect). The average
correlation between therapist’s empathy and client improvement was .30, a
moderate effect size. Elliott et al. noted that there was significant variability
among studies indicating that other variables were moderating the empathy–
outcome relationship. Although therapist’s empathy plays an important role in
general, it has a significantly stronger role with clients who have more severe
problems and a weaker role for therapists with more experience.
Recent research has gone beyond demonstrating that empathy is a crit
ical predictor of client outcome and has examined how empathy influences
client change. The experience of an empathic relational bond influences
client expectancies for change and leads to enhanced motivation for engage-
ment (Westra, 2004). Therapists’ affective attunement helps clients develop
a better relationship with their own feelings (Elliott, Watson, Goldman, &
Greenberg, 2004), and that, in turn, reduces depression, improves self-esteem,
and improves coping ability (Watson, McMullen, Prosser, & Bedard, 2011).
Furthermore, therapist empathic validation of client narratives helps clients
make meaning out of their experiences (Hardtke & Angus, 2004; Kagan,
2007); can help to facilitate insight (Angus & Hardtke, 2007; Castonguay &
Hill, 2007); and helps clients achieve newer, more positive views of them-
selves (Goldfried, 2003; Kagan, 2007). Additionally, therapists’ empathic
understanding enhances the working alliance, and their active empathic
attunement to fluctuations in the therapeutic bond functions as an early
warning system for the detection and repair of strains in the alliance (Safran
& Muran, 2000).
Broader Meanings of Empathy

Bohart et al. (2002) distinguished between three main modes of thera-
peutic empathy: empathic rapport (a compassionate attitude toward the client
that demonstrates an understanding of the client’s experience), communicative

attunement (the moment to moment attunement with the client’s commu-
nication and unfolding process), and person empathy (a sustained effort
to understand the client’s world). Bohart et al. pointed out that humanistic
psychotherapists are likely to emphasize communicative attunement, and
much of the humanistic research on empathy reflects this emphasis.
However, a series of meta-analyses in recent years has drawn atten-
tion to a number of characteristics of the client and the client’s world that
are consistently associated with better outcomes. Clients have better therapy
outcomes when therapists are appropriately responsive to their religion and
spirituality (Worthington, Hook, Davis, & McDaniel, 2011); to their cultural
beliefs and values (Smith, Rodríguez, & Bernal, 2011); and to their personal
beliefs (Constantino, Glass, Arnkoff, Ametrano, & Smith, 2011), desires,
and values (Swift, Callahan, & Vollmer, 2011) regarding therapist behavior
and therapeutic process. Additionally, clients have greater therapeutic gains
when therapists are sensitive to client vulnerability to trauma and loss (Levy,
Ellison, Scott, & Bernecker, 2011) and to client level of resistance or reac-
tance to the therapist (Beutler, Harwood, Michelson, Song, & Holman,
2011). Also, clients have better therapy outcomes when therapists are respon-
sive to their motivation to change (Norcross, Krebs, & Prochaska, 2011) and
to the degree of their reactivity to unexpected changes in the environment
(Beutler, Harwood, Kimpara, Verdirame, & Blau, 2011). In light of this reli-
able body of evidence, humanistic psychotherapists are advised to broaden
their emphasis on person empathy in their therapeutic practice.
Therapist Genuineness or Congruence
Kolden, Klein, Wang, and Austin (2011) found a moderate effect between
therapist genuineness and client improvement in their meta-analysis of 16 stud-
ies. Most of the studies were conducted prior to 2000. The average effect size
in the three post-2000 studies was large (r = .37). Secondary analyses revealed
that congruence is more strongly associated with outcome for more experienced
therapists, for therapists who practice relational therapy, and for clients who
are less educated. Minority status and gender of the therapist did not moderate
the congruence–outcome relationship. However Kolden et al. surmised that a
congruent therapist is probably best suited for clients with a Western cultural
background, though they have no data in this regard. Certainly this is one
of many areas pertaining to therapist characteristics in which multicultural
research is needed.
In a qualitative study relating genuineness to perceived effectiveness of
therapy, Curtis, Field, Knaan-Kostman, and Mannix (2004) asked 75 psycho
analysts to reflect on their own experience as analysands and to describe
the most helpful part of their own analysis. Genuineness was described

as the most helpful aspect of the analysands’ and the analysts’ behavior,
although acceptance, warmth, and emotional availability were also described
as helpful.
Recently, Gelso (2011) offered a two-person view of genuineness that
provides a promising new perspective on genuineness vis-à-vis his articula-
tion of the real relationship. Gelso has offered a view that is entirely con-
sistent with humanistic principles, is evidenced-based, and has generated
considerable research. In Gelso’s formulation, the real relationship between
client and therapist is defined as “the personal relationship existing between
two or more persons as reflected in the degree to which each is genuine with
the other and perceives the other in ways that befit the other” (pp. 12–13).
This definition of the real relationship includes two components: genuine-
ness (very much like Rogerian genuineness) and realism (client and therapist
perception of each other in a realistic way). The realism aspect of the rela-
tionship is certainly compatible with the humanistic view of the client as an
individual who is accurately perceived as a whole person with strengths and
weaknesses by the therapist. However, Gelso’s perspective also adds the idea
of the client’s realistic appraisal of the therapist. For there to be a real rela-
tionship between client and therapist, both must openly express themselves
in a transparent manner, accept each other as they are, and have accurate
perceptions of each other.
In the past decade, Gelso’s work with the real relationship has enliv-
ened the study of genuineness by generating considerable research. Client
and therapist ratings of the real relationship are associated with good thera-
peutic process; are strongly related to depth and smoothness of therapy
sessions (Gelso et al., 2005); and are related to the client’s experience of
therapist empathy (Fuertes et al., 2007), therapist and client ratings of prog-
ress (Fuertes et al., 2007), and with both client and therapist ratings of the
quality and effectiveness of individual sessions (Fuertes et al., 2007; Gelso
et al., 2005). In an interesting study relating the client’s experience of the
real relationship to therapist self-disclosure, therapist self-disclosure was
found to be associated with the real relationship only to the extent that the
disclosures were perceived by the client as relevant to the client’s concerns.
Therapist self-disclosure by itself was not perceived as fostering a real rela-
tionship (Ain, 2008).
In addition to promoting good therapeutic process, the real relationship
is also associated with client improvement (Gelso, 2011; Lo Coco, Gullo,
Prestano, & Gelso, 2011; Marmarosh et al., 2009) and is more predictive of
client outcome than the therapeutic alliance (Gelso, 2011). The average size
of the effect of the real relationship on outcome across these three studies was
large (r = .48), whereas the average effect of the therapeutic alliance was only
moderate (r = .27).

Positive Regard
Farber and Doolin (2011) conducted a meta-analysis of 18 studies that

examine the relationship between positive regard and outcome. The meta-
analytic results indicated a moderate relationship between positive regard
and outcome (r = .27). In secondary analyses, Farber and Doolin found a
stronger relationship between therapist positive regard and client outcome
for those in psychodynamic therapy compared to other therapeutic orien-
tations. Farber and Doolin surmised that the occasional display of warmth
among some psychodynamic therapists may have a demonstrable effect
on outcome. It should be noted that only two of the studies in Farber and
Doolin’s meta-analysis were published since 2000, thus suggesting that the
construct of positive regard may have run its course in the psychotherapy
research community. It is noteworthy that these recent studies were con-
ducted among marginalized populations that are not often the focus of psycho-
therapy research so their findings are of particular merit. Litter (2004) found
that therapist warmth had a strong relationship with outcome among court
ordered youths. Sells, Davidson, Jewell, Falzer, and Rowe (2006) found that
treatment team members’ warmth was related to motivation for treatment
and engagement in treatment programs among dually diagnosed, severely
mentally ill clients. These two studies are important in that these client
populations are more vulnerable to the fiat of public decision makers who
are prone to dismiss humanistic approaches as irrelevant or ineffective with
their client populations.
There have been two notable recent qualitative studies pertaining to
positive regard, and both of these have been with more severely impaired
populations. Traynor, Elliott, and Cooper (2011) explored the experience of
20 person-centered therapists who work with clients experiencing psychotic
processes. Using grounded theory, Traynor et al. inquired about the thera-
pists perceptions of best practices, which were indicated to include “getting
beyond labels and illness,” “working with particular care and attention,” and
“especially with demonstrating unconditional positive regard.”
Gubi and Marsden-Hughes (2013) explored the processes involved
in long-term recovery among eight severely alcohol-dependent individuals
using a phenomenological analysis. Findings suggested that clients’ move
toward long-term recovery involved a need to hear the success narratives of
others and to “strongly experience unconditional positive regard.”
The Nature of Empathy, Positive Regard, and Genuineness
Humanistic psychologists view empathy, warmth, and congruence as attri-

butes of the therapist as a person and not as techniques. What is the evidence

for this? Zuroff, Kelly, Leybman, Blatt, and Wampold (2010) sought to answer
this question in a methodologically sophisticated study that examined the
relationship between therapeutic outcome and a composite measure of thera-
pist warmth, empathy, and congruence. Zuroff et al. used multilevel modeling
to separate the within- and between-therapist effects that are confounded in
most studies. Zuroff et al.’s results support the notion that therapist warmth,
empathy, and congruence facilitate client improvement more so through
being attributes of the therapist as a person who is consistent across clients
rather than through being attributes of the therapist’s technique that might
be “applied” more with some clients than with others. Thus, the best available
research evidence suggests that the facilitative conditions are most effective
when they are conveyed by therapists who are consistently warm, genuine,
and empathic with all their clients.
In the therapy excerpt below, the therapist illustrates an empathic reso-
nance and genuine affective expression, which is clearly not a techniques
but an expression of the therapist as a person. The client is a college student
at an Ivy League school, the son of prominent figures in his community. He
describes experiences at his summer job in a day camp for children.
Client: She sits apart from the other kids and doesn’t play with
them. [From his earlier narrative, the therapist knows that the
client grew up feeling like he had to play the role of being the best
student in school and did not relate socially to others.]
Therapist: You’re sensitive to how she feels.
Client: I’m the only one she asks for help. She doesn’t like to go
across the play area by herself. She asks me to get water for
her. I don’t get it for her, but I walk with her so she can get
it for herself.
Therapist: You’ve developing a relationship with her.
Client: I look forward to seeing her the most every day. I work with
all the kids but I am especially connected with her. [pause]
My parents think I’m an embarrassment because I work with
children. They want to be able to brag that I’m an intern in
a high-powered firm, not a camp counselor. But it feels like
this is where I need to be right now.
Therapist: There’s something very meaningful in working with these
kids and with this girl especially.
Client: It’s like I know how they feel. They’re so transparent. They
can’t hide their feelings even if they tried. [The client’s gaze
was averted downward. He had often reported feeling judged
by others and uncomfortable with eye contact. The client didn’t
appear to be looking at the therapist but he did notice tears welling

up in the therapist’s eyes.] I’m amazed you’re crying. You know
how I feel. No one else knows how I feel. [pause] I thought I
had to hide my feelings because of what people would think.
[pause] I’m not going to hide my feelings anymore.
In this excerpt, the therapist’s empathy opens the door for the client’s
exploration of the affective meaning of his work with children. The therapist
had been touched by the deeper meanings implicit in the client’s developing
narrative. The therapist’s empathic, genuine, and real expression of affect—an
intrinsic expression of who he is and what he understands as a person—led the
client to embrace a more genuine and deeper relationship with himself and
to consider being more genuine in his relationships with others. This excerpt
illustrates the development of relational depth (Mearns & Cooper, 2005), a
concept that articulates the movement from relatively superficial levels of
relationship evident in the earlier stages of therapy to deeper levels of mutual
engagement that are made possible when a relationship is characterized by
empathy, genuineness, and positive regard.
Therapist Presence
The therapist’s behavior in the preceding vignette also illustrates thera-
pist presence. Perhaps no concept seems to express the essence of the human-
istic therapists’ contribution to therapy more than the concept of therapeutic
presence (Geller & Greenberg, 2012). Therapeutic presence is more than
facilitative conditions. According to Geller and Greenberg (2012), it involves
contact with self (i.e., checking in inwardly with what is being experi-
enced), deep contact with the client (i.e., felt experience of being with
and for the other, attuned deeply to the other’s present moment experi-
ence), and contact with a deeper sense of intuition, spirituality, or a
transcendental force. (p. 140)
Research on presence suggests it can be reliably measured and is mean-
ingful related to therapeutic process and outcome. Guided by a qualitative
study based on interviews of seven master therapists who have articulated
a conceptualization of presence, Geller, Greenberg, and Watson (2010)
used scales to rate therapist presence (a client and therapist version). These
scales were used as part of two randomized controlled trials that compared
process experiential person-centered and cognitive behavioral therapies.
Client improvement was associated with client rating of therapist presence.
Furthermore, clients rated the therapeutic alliance as stronger in sessions in
which they experienced the therapist as more present. Thus, presence seems
to be an important predictor of therapeutic alliance. However, therapist per-
ceptions of their own presence were not related to clients’ ratings of outcome
or alliance. This is a finding that is consistent with other findings that client

ratings of the therapeutic process variables are more predictive of outcome
than therapist ratings.
The Therapeutic Alliance

There is good reason to believe that the therapeutic alliance can be con-
ceptualized as a therapist relational variable. An important study by Baldwin,
Wampold, and Imel (2007) used causal modeling to differentiate the overall
effect of the alliance on outcome into the separate components attributable
to the therapist and the client. The results suggest that the alliance–outcome
relationship is due more to the therapist’s capacity for establishing a col-
laborative relationship with a range of clients than the client’s capacity to
establish or respond to a constructive relationship. Thus, the formation of
the alliance has more to do with the person of the therapist and therapist
consistency in developing an alliance across a variety of clients than with
the client or specific client–therapist pairings. This is consistent with the
findings of Zuroff et al. (2010) indicating that the facilitative conditions,
essential to the formation of the alliance, are also more effective when they
are more intrinsic to therapists’ practice rather than used as techniques that
are practiced more with some clients than with others.
Research evidence for the relationship between the alliance and outcome
has continued to grow since 2000. Horvath, Del Re, Flückiger, and Symonds
(2011) found a moderate effect size (r = .28) in their meta-analysis of 190 stud-
ies. Of note is the finding that client and observer ratings of alliance have
a stronger relationship with outcome than do therapist ratings of outcome.
Though this finding fails to reach significance, it is consistent with the relative
weakness of therapist ratings in predicting outcome from a variety of relation-
ship variables. As with the facilitative conditions, the alliance–outcome rela-
tionship was not influenced by theoretical orientation. Additionally, when the
alliance was measured at different points in the course of therapy, it was noted
that a declining alliance was associated with poor outcome in contrast to the
good outcome associated with a consistently strong or improving alliance.
Horvath et al.’s (2011) findings parallel the findings regarding the
alliance–outcome relationship in separate meta-analyses of couple and family
therapy (r = .26; Friedlander, Escudero, Heatherington, & Diamond, 2011),
group therapy (r = .26 for cohesion–outcome relationship; Burlingame,
McClendon, & Alonso, 2011), and child and adolescent therapy (r = .19;
Shirk & Karver, 2011). Thus, humanistic therapists are advised to be con-
cerned about the development of the alliance and to be humble about their
ability to accurately judge its strength.
Looking at the relative roles of the client and therapist from another
perspective, Rozmarin et al. (2008) took an intersubjective approach to

assessing the impact of the alliance on outcome. In addition to the typical
therapist and client ratings of the alliance, they computed the correlation
between therapist and client ratings of the alliance, thus obtaining a measure
of client–therapist agreement. This intersubjective measure of the alliance
was twice as strong as either client or therapist alliance ratings alone in pre-
dicting outcome (r = .61). Measuring the degree to which client and therapist
agree on their perception of the alliance is theoretically consistent with the
concept of the alliance as collaborative and is more powerful in predicting
outcome than unilateral measures of the alliance. It seems that both client
and therapist have something to say about the alliance, and when they agree,
that, in and of itself, is a better measure of the alliance than either one’s per-
spective alone.
Repairing Alliance Strains and Ruptures

Alliance strains and ruptures are common. In a review of four recent
studies pertaining to alliance ruptures, Safran, Muran, and Eubanks-Carter
(2011) found that, on average, clients reported having a rupture experience in
35% of their sessions, whereas therapists judged ruptures as occurring in 53%
of these same sessions. Typically, alliance ruptures are assessed by either post-
session questionnaires or by ratings of clients’ in-session behavior. According to
Muran et al. (2009), postsession questionnaires ask questions such as “Did you
experience any tension or problem, any misunderstanding, conflict or disagree-
ment, in your relationship with your [therapist/patient] during the session?”
(p. 237). Therapist or raters assess clients’ in-session behavior along two dimen-
sions: withdrawal from engagement with the therapist or therapeutic process,
or confrontation by the client with an expression of some dissatisfaction with
the therapist or therapy.
When ruptures are detected, it is important to repair them. Safran et al.’s
(2011) meta-analysis of three studies that investigated the relationship between
rupture repair and outcome found a moderate effect (r = .24), indicating that
rupture–repair episodes are predictive of good outcome. In one illustrative study,
lower rupture intensity predicted good outcome, and more rupture resolution
predicted better retention in therapy (Muran et al., 2009). In another inter-
esting study, Strauss et al. (2006) divided clients into two groups based on the
number of rupture and repair sequences they experienced. All of the clients
who had experienced more rupture and repair episodes had clinically signifi-
cant improvement (defined as a 50% decrease in symptoms during the course
of therapy). In contrast, only 45% of those categorized as having low rupture
and repair achieved clinically significant improvement. Additional research
suggests that it may be particularly difficult for some therapists to repair strains
caused by their rigid allegiance to a preferred therapeutic orientation. Such

situations have been strongly associated with negative outcomes (Castonguay,
Boswell, Constantino, Goldfried, & Hill, 2010). It is apparent that alliance
ruptures provide critical opportunities for improvement in therapy if they are
recognized and handled appropriately.
Safran et al. (2011) noted that there is an evolving qualitative research
paradigm that is providing insights into rupture and resolution processes.
For instance, according to Safran et al. (2011), in withdrawal ruptures in
which the client disengages from some aspect of the self, the therapist, or the
therapeutic process, the resolution consists of the client “moving through
increasingly clear articulations of discontent to self-assertion in which the
need for agency is realized and validated by the therapist” (p. 234). Because
most clients are likely to experience alliance ruptures and because many
clients may experience ruptures a number of times during the course of ther-
apy, detecting and responding to these ruptures is critical.
The following clinical vignette illustrates an impending rupture as well
as the therapist’s role in repairing it. The client is a 23-year-old single woman
with no prior therapy experience. The excerpt is from early in the first session.
Client: A little while back I was having a rough day at work and I
called my boyfriend for some support. We had a fight over
his being such a jerk about what happened. I should have
known better than to try to talk to him about emotional
stuff. So on the way home I met a girl friend for dinner and
had a couple of drinks to relax and talk. Then, I was stopped
by the police on the way home. I blew just over the limit for a
DUI [driving under the influence]. Now on top of everything
else I’ve got the hassle of dealing with the court. I don’t have
a problem drinking, and I’m definitely not an alcoholic.
Therapist: Wow that was really an awful day.
Client: Yeah, it’s so bogus that I have to deal with a DUI now.
Therapist: That’s not what you need at this point in your life.
Client: I was thinking that if you would write a letter letting them
know that I don’t have a drinking problem, I wouldn’t have
to waste my time and money dealing with the court.
Therapist: The policy of the clinic is not to write letters to the court
after just one meeting.
Comment: Here the client defines a goal of meeting with the therapist—to
get a letter from the therapist so that the court will go easy on her. In contrast,
the therapist had been hoping for a more motivated client and speaks unem-
pathically and abruptly in a limit-setting way and also does not take direct
responsibility for not writing the requested letter that day.

Client: I thought you’re supposed to help. [The client’s critical com-
ment suggests an impending therapeutic rupture.]
Therapist: [The therapist realizes his mistake with the help of the client’s reac-
tion.] I’m sorry. I didn’t communicate what I meant to say
very well. I can write a letter on your behalf, but I couldn’t
say much after only meeting you for an hour. If you need a
letter for the court, I’d like to write one that honestly por-
trays you. This would usually include a description of your
strengths and coping skills as well as the stresses in your life.
Would that be the kind of letter you would like me to write?
Client: I guess so. I was hoping I could just take care of this today and
then not have to worry about it.
Therapist: It’s a disappointment that we can’t get that accomplished
today. It will take us a few sessions before our conversations
will allow me to write you a good letter.
In the dialogue above, the therapist has averted a rupture for the time
being and has proposed a tentative goal of meeting for a few sessions during
which he hopes to engage the client in a therapeutic process. Additionally,
the therapist broadly outlines tasks, issues to address in the letter that the
client wants, and solicits the client’s collaboration on these tasks. The nego-
tiation of these goals and tasks together with the bond created by the thera-
pist’s empathic attunement to the client constitute the initial building blocks
of the alliance.
Difficulties With Providing Facilitative Conditions and Maintaining the Alliance

While recognized by humanistic therapists, the personal limitations
and challenges of clinicians with offering facilitative conditions that foster
the alliance have not often been a systematic focus of the humanistic litera-
ture (Elliott, 2013; Gelso & Hayes, 2007). Recently, Elliott (2013) addressed
this issue by articulating an approach to the therapist’s struggles with pro-
viding facilitative conditions. He used the term negative therapist reactions
to refer to therapists’ empathic failures, conditionality, negative regard, and
incongruence. Although Elliott’s contribution to understanding therapist’s
problematic reactions has important clinical implications, it has not, as yet,
spawned a research basis. Therefore, research outside the humanistic lit-
erature, the research pertaining to countertransference (CT), is examined.
Empirical studies generally consider CT as arising from therapist’s issues that
are triggered by client characteristics such as dependency, passivity, aggres-
siveness, or dismissiveness. Most research on CT has examined either inter-
nal or external manifestations of CT. Internal manifestations of CT may be

reflected in therapist anxiety, anger, boredom, despair, arousal, disgust, and so
on. External manifestations of CT are reflected in therapist negativity toward
or avoidance of client topics. CT may also manifest itself in therapist failure
to accurately recall therapy content, to misperceive therapy process, and to
misjudge clients as overly similar or dissimilar to themselves (Hayes, Gelso,
& Hummel, 2011).
In their comprehensive review of the research on CT, Gelso and Hayes
(2007) concluded the following:
1. CT thoughts and feelings are common but infrequently expressed
in outright behavior;
2. therapist avoidance is the most frequent expression of overt CT
and is manifest in changing the topic, ignoring clients’ feelings,
or making emotionally distancing comments; and
3. the principal effect of CT is to strain the therapeutic alliance
that, if not repaired, is likely to have a negative impact on client
outcome.
Managing Countertransference
In early work with addressing therapists’ management of their CT, Van
Wagoner, Gelso, Hayes, and Diemer (1991) developed the Countertransference
Factors Inventory (CFI). The CFI consisted of five factors: self-awareness, anxi-
ety management, empathy, self-integration, and conceptual skills.
In a survey asking 122 therapists to nominate colleagues whom they
considered to be excellent therapists, those who were deemed as excel-
lent were rated higher on all five of the CFI scales relative to the ratings of
therapists in general. With the exception of CT conceptual skills in which
humanistic therapists were rated relatively low compared to psychodynamic
clinicians, none of the other CT management characteristics differed as a
function of theoretical orientation (i.e., humanistic, behavioral, or psycho-
dynamic). Humanistic therapists’ low level of conceptual skills with manag-
ing CT is not surprising in light of humanistic psychology’s failure to develop
a theoretical framework regarding CT until recently.
Hayes et al.’s (2011) meta-analysis found that CT, as most often mea-
sured by ratings of therapist avoidance of client issues, had a significant but
small negative effect (r = -.16) on outcome in 10 studies. However, CT
management, most often measured by the CFI, had a significant, large, and
positive effect (r = .56) on outcome in seven studies. Thus, this literature
indicates that CT issues and their management have a significant effect on
client outcome. Of note, therapists’ self-ratings of their CT management had
a much smaller relationship to outcome (r = .18) than therapist CT ratings
by others (e.g., supervisors; r = .62). This echoes findings regarding therapists’

limitations when rating their facilitative conditions and the quality of their alli-
ance reported earlier. Clearly, the implications of Gelso et al.’s meta-analysis are
that humanistic theory, research, and practice would be benefited by atten-
tion to CT and CT management.
CASE STUDY: THE GOOD HUMANISTIC THERAPIST

AND THE HIGH-RISK CLIENT
In this section, we present an extended sequence of an initial consul-

tation that exemplifies best practices of humanistic therapy in general and,
specifically, with a high-risk client.
The client, a chronically depressed and suicidal woman in her mid-40s,
was referred for an initial consultation with the therapist by a relative who is a
professional colleague of the therapist. In the first 10 minutes of the session, the
client expressed a long list of overwhelming problems, including her husband’s
recent diagnosis with cancer, her fears of abandonment, and her and her son’s
substance abuse. The therapist had, up until this point, focused on being avail-
able to listen empathically. He was feeling a bit overwhelmed by the rapid out-
pouring of her problems and by the emergence of the client’s suicidal ideation.
Client: I don’t know what I’m going to do with myself. You know
what I mean? Because it’s just way too overwhelming.
Therapist: It feels that way. [This statement might have been perceived as
empathically misattuned.]
Client: Um hum . . . It feels more than that way . . . Like it . . . I don’t
know . . . I mean I really don’t know what I’m going to do.
I’m kind of afraid . . .
Therapist: Do you have something in mind that you’re afraid of?
Client: I don’t see the value of continuing this . . . stuff.
Therapist: Therapy? Life?
Client: No, not therapy.
Therapist: Stuff like?
Client: Let me just ask you this . . . you asked me, “Life”? So if I say
“Yes” to that, is there something you’re going to do about it?
Therapist: If that’s an issue or a problem, I’d like to help you with it.
Client: Will you guarantee that you’re not going to say anything
about it? Will you guarantee me that you’re not going to tell
my family, tell everybody? So that they’re calling me all the
time? Are you going to tell anybody?

Comment: The client’s question is difficult to answer. How it is answered
will be important for the development of an alliance. The therapist is aware
of the multiple meanings of safety at this moment. For the client, safety in
this moment means uncompromised confidentiality to protect her from the
intrusions of others. The therapist appreciates the client’s perspective but also
knows that there may come a time when contacting specific others might be
required to maintain the client’s safety from her own life-threatening impul-
sive actions. The therapist wants to build an alliance grounded in safety
and respect for the client’s wishes by finding a consensual way to handle the
question of what to do about telling others. Additionally, the therapist feels
challenged to manage his own anxiety stirred by the client’s suicidal feel-
ings. Therapists frequently try to assuage their own anxiety by controlling the
client with no-harm contracts and hospitalization. The therapist decides to
try to tolerate his anxiety aided by remembering his successful experiences
with helping suicidal clients in the past.
Therapist: I’m not sure. I guess my concern is that if you were in imme-
diate danger of hurting yourself I’d like to do whatever it
took to help you. But I don’t know what it would take.
Client: What if you think helping me is telling them? How do you
expect me to be open with you? What if you think that help-
ing me is telling everyone?
Therapist: Yes, that’s an important concern. The issue is not just what
I think is helpful, but what you think is helpful too.
Client: Okay, but what if I know I’m done.
Therapist: Done with?
Client: Life.
Client: What if I were to say, “I’m going to end my life.”
Therapist: “Would you like to talk about it?” That’s what I would ask,
“Would you like to talk about it?”
Client: Yeah, but when my family starts calling me asking, “Are you
okay? Are you okay?” It drives me nuts. I don’t need my hus-
band worried. He’s sick. I don’t need my son to worry.
Therapist: You don’t need more pressure, but it would be good to talk
about things.
Client: If I said to you, “I don’t need help. I just need to talk and I’m
going to be honest with you.” Would you promise not to tell
anybody?

Therapist: I’d like not to tell anybody. I don’t know that I can promise
to do that forever. If you say I’m going to walk out this door
and step in front of traffic. I would want to do something to
stop that, to give you more time to think it over.
Client: Okay, I won’t tell you that.
Therapist: But if you want to say, I feel like walking out the door and
stepping in front of traffic. That’s something we can talk
about. You see the difference?
Client: I do, I just don’t want to get mad at you at the back end and
say, you f*cked me over.
Therapist: I don’t want us to get in that situation either, because then
it would be difficult for us to work together.
Client: You are pretty much the only one I can talk to about this.
So I really, really, really want to trust you . . . The drink-
ing escape is like short-lived, and there’s this impact on my
thinking and its worse . . . My thought is if I could slip away.
You know how you said a little while ago, slipping away? So
if I could slip away. I wouldn’t be around for my son to see
me drinking. And so I just can’t do this anymore.
Therapist: Not alone, not without support.
Client: But the support I keep thinking about is people calling me
and nagging me. “Are you okay, are you okay, are you okay?”
I don’t want that support.
Therapist: That’s not support. They’re anxious and worried . . . that’s
giving them support.
Client: That’s just giving me another reason . . .
Therapist: Yes another headache . . . so that’s not real support. Not sup-
port for you.
Client: What do you think is real support?
Therapist: Someone being able to listen to what’s going on with you
and not put extra demands on you. Not having to mind
someone else’s feelings, just your own.
Comment: The therapist has been empathic about the client’s need to talk
about suicide and her parallel concerns about confidentiality and the intru-
sion of others. The client seems to be accepting a temporary working alli-
ance over the issue of talking with conditional confidentiality aided by
the therapist’s empathic understanding of the client’s experience of family

“support” as not supportive. Additionally, the therapist, by validating the
client’s experiential definition of support sets the stage for helping the client
value her personal experience.
Client: I want to kill myself.
Therapist: It feels like the only way out right now. [The challenge here
is to empathize with the suicidal feeling without supporting the
suicidal decision.]
Client: It would be different if I thought there were other options
but I’ve been looking at this for a long time. It’s been an
ongoing theme in my life for this last month. It’s really given
me a lot of reasons to look at what are my options . . .
Therapist: This month you’d hoped it would turn around. That you
could find some options but you haven’t found any yet.
Client: You said “hope” but the reality is I don’t have any hope any-
more. What am I going to do without my husband? He’s
always been my best friend, everything.
Therapist: It’s hard to imagine losing him and yet you are imagining
losing him.
Client: I know. He’s been with me since I was in high school.
Therapist: It’s been a long time—a whole lifetime. You’re really scared.
Scared about losing him. He’s here today, tomorrow, next
month. You don’t know for how long. It scares you so much . . .
imagining losing him . . . preparing.
Client: He’s always been around to help balance my son and me out,
I don’t know how we’re going to live. How we’re going to do
it. It’s so depressing, and I, I can’t talk to him anymore about
my feelings because I’m supposed to be so supportive of the
family. [pause] I’ve even thought about a way to . . .
Therapist: A way to . . . ?
Client: If I tell you, then you’re going to tell people and they’re going
to get it out of the house, and then I’ll have no control. Zero
control. [The client subsequently admits to having a gun.]
Therapist: You’d be the first person I’d talk to if there is something in
the house that you were thinking about killing yourself with,
and you thought you weren’t able to control using it, then
you would be the first person I would talk to about it.
Client: Then if I said, “No, just leave it alone,” that’s not important?
Therapist: I don’t know how important it is. I think you’re worried
about losing control.

Client: I am . . . It seems like a lot of what we’re talking about is
trying to have some sense of control. There’s already enough
lack of control. Which is probably why I’m feeling as bad as I
do. See what I’m trying to figure out here is, what am I doing
here? Why? . . . I have this plan, and I know what I’m going
to do. And I’m here, and I don’t know. Whether I want you
to fix it, like a fairy godmother.
Therapist: Maybe you want other options . . . More control, so there’s
not just one choice.
Comment: The therapist has been empathic with the client about her fears of
loss (husband’s death, family intrusions, loss of self-control) and her suicidal
thinking as a way to feel in control of something. They are working more
collaboratively, processing her experience in the context of a genuinely sup-
portive relationship. She had been imagining her husband dead and herself
as intolerably alone. The client begins to feel hope as manifest in seeing more
options and in experiencing a developing relationship with the therapist.
The therapist and client discuss her gun as something that both gives her
a comforting sense of control as well as something that frightens her. They
collaborate on a way to give up the gun while preserving a sense of control.
Client: Okay, maybe there are some options . . . some hope. But
when I get home I can’t guarantee that I’m not going to . . .
Therapist: Lose whatever hopeful feelings you have right now.
Client: I really don’t know.
Therapist: Right, you could have a setback.
Client: I could kill myself.
Therapist: Exactly.
Client: Doesn’t that scare you? It’s scaring the shit out of me.
Therapist: I don’t know the details, so I’m not as scared as you are,
because you can picture it . . . what you might be thinking
of doing.
Client: I can make a picture.
Therapist: I don’t have that picture so it’s not as scary for me.
Client: See this friend of mine committed suicide. She wrapped her-
self in a carpet and shot herself. She was concerned about
the mess. I would do that too because it’s not very nice to
leave a mess.
Therapist: You’re thinking, about other people, your husband and son,
what they would see?

Client: What am I going to do if I want to do that? What if it just
carries me away, because I think there’s a part of me that
doesn’t want to . . .
Therapist: I know. I hear. The part of you that doesn’t want to die is a
little bigger than when you came in but you’re not sure how
big it will be after you leave. That part that wants to live, we
can only help that and nurture that only so much today. It’s
going to take us some time.
Client: Is it fake?
Therapist: Does it feel fake?
Client: [pause] No.
Comment: The therapist is exploring both sides of the client’s ambivalence.
The client asks if the hope she feels is real. The therapist does not answer for
her and empathizes with her experience—the hope is real in this moment,
but both know it may not be persistent.
Therapist: That’s a good question—how are you going to hang on to
this? Because things may happen that make it hard to hang
on to this feeling of hope. I think we need to have a plan,
some sessions, and a plan to get from one session to the next.
So you can build on this foundation. And not lose what you
get, or if you lose it, get it back.
Client: I’m just thinking, “How am I going to keep it? How am I
going to carry it for a week?”
Therapist: Well, maybe a week is too long.
Client: I’m afraid of the week.
Therapist: So carrying it until next Tuesday is too long. What about
making a plan to meet later this week?
Client: Can we do that?
Therapist: Yeah.
Comment: The therapist is having some sense of relief now that the client is
scared about losing control and asking for help. At this point, therapist and
client are no longer negotiating. They have agreed to a goal, to maintain the
client’s sense of control. Now there are options and hope as an alternative to
suicide. Suicide in no longer a solution to a problem but a problem itself on
which the therapist and client can both agree. They are collaborating. This
is a good beginning to developing a therapeutic alliance.
Client: Okay, but see here’s the thing. So, we think we’ll meet on
Friday, and I’ll be okay, what, what if something really does
happen?

Therapist: What to do then? What to do between now and Friday when
something happens, what can you do?
Client: I think I’ll need to call.
Therapist: Okay.
Client: Can I call you?
Therapist: Here’s my number on my card.
Client: Okay.
Therapist: It’s sometimes hard to get through to me right away. [The
therapist is trying to establish realistic parameters for his avail-
ability and plans for developing other resources.]
Client: But if I don’t need you I wouldn’t call.
Therapist: I know. If you call me, it might take me a few hours to get
back to you.
Client: Do you have a pager?
Therapist: I’m in places sometimes where I can’t return a call . . . in
session or teaching. Sometimes it takes a few hours . . .
Client: But it’s my life!
Therapist: I know. Let’s talk about how it might take you half a day
sometimes. That’s a possibility.
Client: Like I can get you.
Therapist: Yeah.
Client: What if I called you in the middle of the night. You wouldn’t
be working.
Therapist: I’d probably be sleeping.
Client: Okay, then you’ve got to give me an alternative.
Therapist: And you don’t think you can make it for a few hours. So
another possibility is to call the crisis line. Usually it’s staffed
by volunteers who are available 24/7 to talk to people.
Client: Do they know what they’re doing?
Therapist: Some do. Some are great. Some are just getting started.
Client: Are they going to call the cops?
Therapist: It’s anonymous.
Client: It is?
Therapist: Yeah.

Client: They wouldn’t know.
Therapist: They wouldn’t know.
Client: And then you’d still call me back in a couple of hours.
Therapist: Right.
Client: And if I needed to come see you, I could come see you sooner
than Friday.
Therapist: You could.
Client: Do you think I need to tell anybody? Like besides you?
Therapist: I think it would be good if you had someone to talk to besides
me.
Client: I’m just running through who I could talk to, and I’m think-
ing my son’s got a lot of shit and so does my husband. If I tell
someone else, they’re going to want to tell my husband.
Therapist: What about your husband? You don’t think he’s ready to
have this conversation?
Client: I’m afraid I’m going to kill him sooner. [She is afraid that by
telling him she is suicidal that she will kill him sooner.]
Therapist: If he knows that you’re trying to do something about this.
Knows you’re struggling to survive. It might help him.
Client: Do you think I’m going to kill him?
Therapist: I think it would be more stressful for him not to know and
later find out you didn’t want to talk to him. I don’t know if
you guys are ready for that conversation yet, but I’m thinking
at some point he’d want to know and want to know if there
was something he could do to help.
Client: Like I’m so concerned about him; if I did something to myself
and didn’t talk to him he’d feel so betrayed.
Comment: The client and therapist have collaboratively developed a plan
that the client feels will keep her safe between now and their next meeting.
It is interesting that this plan is very much like a no-harm contract except
that it was negotiated by the client on a moment-to-moment basis through
a collaborative process that built the therapeutic alliance. Sometimes thera-
pists have difficulty managing their anxiety and pull out a contract or make
a referral for a medication evaluation or hospitalization. This client would
likely have experienced such behavior as akin to her own experience of fam-
ily’s disingenuous offer of “support.” Feeling some relief and not so fearful
of the control of others, the client feels more in control, sees the therapist

and others as potentially helpful, and can turn to the issue of whom else she
can talk to with a greater sense of controlling her boundaries. As therapy
progressed with this woman, the therapist’s greatest challenge was to remain
calmly supportive and present when she went through cycles of emotional
dysregulation. Over time she was able to develop greater self-regulation and
mastery over her sense of being out of control.
CONCLUDING REMARKS
The research evidence overwhelmingly supports the conclusion that

good therapeutic outcomes are associated with therapists’ strong relational
qualities. First among these relational qualities are the facilitative conditions
postulated by Rogers (1957) more than half a century ago. These qualities
have achieved such a broad research basis that they are now considered by
most therapists as core therapeutic ingredients in all effective psychotherapies.
What is of particular note in the recent literature is the development of the-
ory and research that suggests that these relational qualities are most effective
when they are intrinsic to the person of the therapist, thus supporting the
notion that the personal presence of the therapist is particularly important
to the therapeutic process. Also, with regard to the person of the therapist,
humanistic research has recently become interested in therapists’ personal
reactions that can have a negative impact on the therapeutic process.
Negative therapist reactions and CT phenomena are important to outcome
and are clearly related to therapists’ personal awareness, into their presence
as a therapist. Humanistic psychotherapies have lagged behind some other
therapeutic approaches in formulating theory and producing research evi-
dence in this area.
Recent research has moved toward articulating a more relational view
of the therapeutic process in psychotherapy. Thus, the alliance between client
and therapist and the inevitable strains, ruptures, and repairs of this alli-
ance have been recognized as critically important to the success of therapy.
Additionally, the research suggests that the relationship evolving from the
genuine expression and acceptance of the real selves of both client and
therapist is an important predictor of depth and client transformation in
psychotherapy.
Although contemporary research attests to the general effectiveness
of therapists and of specific therapist relational qualities, there are some
cautionary and humbling findings for therapists to consider. Although most
clients are helped by therapy, too many are not. Even the best therapists have
some poor outcomes, and clients of average therapists fare much worse. The
research suggests that therapists have something to do with poor as well as

good outcomes. Therapists’ perceptions of the therapeutic process are less
predictive of outcome than clients’ perceptions. Clearly, clients do not always
share their negative feelings about therapy with their therapist, but it is also
clear from the CT literature that therapists are sometimes not listening or
responding when clients do share. It has been suggested that therapists con-
duct routine, formal assessment of client process periodically throughout ther-
apy (see Chapter 2, this volume). More research is needed to improve therapists’
systematic practice in detecting and intervening when strains in the therapeutic
alliance threaten the therapeutic endeavor.
It is shocking to realize that therapist effectiveness does not generally
improve with professional experience. The fact that therapists’ confidence,
if not their expertise, grows with experience helps explain this unfortunate
state of affairs. Therapist motivation to systematically learn from their work
with clients and from ongoing professional training can be undermined by an
unrealistic sense of confidence in one’s therapeutic effectiveness. Hopefully,
more therapists will appreciate that personal and professional growth are a
life-long process.
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14
CLIENT VARIABLES AND
PSYCHOTHERAPY OUTCOMES
DAVID M. GONZALEZ
After years of reviewing psychotherapy research, Bergin and Garfield

(1994) came to the conclusion that as therapists depend more on the cli-
ent’s resources, more change seems to occur. Recognizing the central posi-
tion of the client to therapeutic success seems essential if we are to grasp a
more complete picture of therapeutic success and failure. In fact, researchers
have come to recognize that client variables likely determine the outcome of
psychotherapy more than all other variables combined. In 1992, Lambert
estimated that 40% of the outcome can be attributed to the client and fac-
tors in the client’s environment. More recently, Wampold (2010) noted that
client variables are the best predictors of outcome.
Orlinsky, Rønnestad, and Willutzki (2004) documented that variables
attributed to clients have proven to provide the most accurate prediction
of outcome. Orlinsky, Grawe, and Parks (1994) noted that “the quality
of the patient’s participation in therapy stands out as the most important
http://dx.doi.org/10.1037/14775-015
S. Rubin (Editors)
455
determinant of outcome” (p. 361). In their review of research related to cli-
ent variables, Bohart and Greaves Wade (2013) described the client “as an
active learner and problem solver who contributes to the therapy process and
outcome” (p. 219). However, researchers have come to appreciate the fact that
studying discrete client variables is important and yet a challenge. There is an
inherent difficulty in isolating a single client variable from a relational pro-
cess in which multiple variables contribute to the therapy outcome. Clients
do not live in a vacuum. Anyone can stand alone in the middle of a field and
declare oneself to be a great person. The statement only has meaning when
all that composes an individual interacts with the environment, the com-
plexities of people, and the various situations one encounters. Despite these
and other limitations involved in conducting research on client variables,
there are a number of informative studies that can assist us in understanding
and appreciating client variables related to psychotherapy outcome.
In searching for information about client variables and psychotherapy
outcome, some of the more recent studies have extended and confirmed prior
research. Furthermore, some research has introduced a modification in think-
ing about how best to study the effectiveness of psychotherapy. Some recent
studies have attempted to ascertain more specific information from the cli-
ents themselves, not only about what they perceived as helpful but also how
the change came about. What follows is a review of the major studies on
client variables and outcome prior to the year 2000, followed by a look at the
research done in this area since the year 2000.
RESEARCH ON CLIENT VARIABLES

AND OUTCOMES PRIOR TO 2000
Finding research that could support unequivocal statements about the

association between client variables and outcome has been an elusive endeavor
until more recent years. In fact, Garfield’s (1994) review of research on client
variables and outcome found little in which to be confident. He noted the dif-
ficulty in forming definitive conclusions about client variables because many of
the studies defined and measured outcome differently or may have had design
and analysis weaknesses that raised caution in interpreting the meaning and
generalizability of the results. Also, there have been contradictory findings in
the research.
Bohart and Tallman (1999) argued that it is the client who primarily
determines the outcome of psychotherapy. They cited a number of studies
to support their contention. For example, more than 60% of clients arriv-
ing for their first session reported improvement in the presenting problem
since the appointment was made (Lawson, 1994; Weiner-Davis, de Shazer,
456 david m. gonzalez

& Gingerich, 1987). Also, many clients reported improvements following a
single session of therapy (Rosenbaum, 1994). Clients appeared to make gains
without the assistance of the therapist, providing support for the notion that
clients have their own capacity for self-healing. Bohart and Tallman (1999)
suggested that therapists may activate the client’s potential for self-healing
by various interventions, but it is really a matter of the client tapping into
his or her own resources for self-healing that constitutes the actual therapy.
A number of studies conducted at the University of Chicago Counseling
Center in the 1950s examined the effects of client-centered therapy. The
studies were conceptualized from a client-centered perspective, and the ther-
apists were all trained in that approach. Rogers (1954) provided a summary
of the results. An important finding that received empirical support in these
studies was that a relationship in which the client developed a strong liking
and respect for the therapist was the type of relationship most associated
with positive outcomes in psychotherapy. In essence, a warm relationship
containing mutual liking and respect was more likely to lead to success. Also,
during the therapy sessions themselves, the most notable behavior was that
the client began an exploration of the self and moved away from talking
about external problems. The interviews became less intellectual or cognitive
and more an emotional or experiencing process (feeling and being). Rogers
(1954) observed that “experiencing the complete awareness of his or her total
organismic response to a situation is an important concomitant of the process
of therapy” (p. 425).
In the Chicago studies, a change in the client’s perception of the self
appeared to be a central factor in the process of client-centered therapy. Of
those clients considered to be successful, new perceptions of the self emerged
into awareness. Rogers (1954) noted that there was some evidence that the
emerging perceptions of the self were based on material previously denied
to awareness. The client typically began one’s therapy with an intellectual
discussion of the problem then moved toward an exploration of the self.
Additional findings were that clients with at least moderately democratic
and accepting attitudes toward others seemed to reap the most benefit from
therapy. Last, Rogers noted that he did not find any relationship between
initial diagnosis of the clients and outcome of therapy and, in fact, found
that the deeply disturbed progressed equally as well as the mildly disturbed.
CLIENT PARTICIPATION/ENGAGEMENT/INVOLVEMENT
According to Greenberg and Pinsof (1986), the degree of client

involvement is a predictor of outcome. They stated that the findings from
“alliance-related work show that patient participation, optimism, perceived
client variables and psychotherapy outcomes 457

task relevance, and responsibility are related to change” (p. 13). Along the
same lines, Gomes-Schwartz (1978) examined ratings from taped therapy
sessions and found that the variable most predictive of outcome was the
client’s willingness and capacity to actively engage in the therapy process.
Active engagement was defined as having a positive attitude toward the thera-
pist and therapy as well as a commitment to working at change. In this par-
ticular study, psychoanalytically oriented therapists, experiential therapists,
and college professors popular with students—but not trained in doing
psychotherapy—were compared. All three groups of therapists had similar
outcomes, with the level of client involvement emerging as the best pre-
dictor of outcome. Similarly, Orlinsky et al. (1994) summarized 54 findings
regarding client role engagement reflecting the personal involvement of par-
ticipants in the client role. Of the 54 findings, 65% showed a significant
positive association with outcome. They also summarized 28 findings on cli-
ent motivation, defined as the perceived desire for therapeutic involvement
by participants in the client role. Half of the findings showed a significant
association with outcome. When this variable was looked at strictly from the
client’s perspective, the percentage rose to 80%.
Therapeutic Alliance
In a 1982 study, Moras and Strupp concluded that the level of inter-
personal relations prior to beginning therapy predicted clients’ level of col-
laborative, positively toned participation in a therapeutic relationship. Filak,
Abeles, and Norquist (1986) investigated whether clients’ interpersonal atti-
tudes prior to beginning therapy related to an affiliation–hostility dimension
would have a significant impact on therapy outcome. Of those with an affilia-
tive stance, 72% had a highly successful outcome, whereas only 38% of those
with a pretherapy hostile interpersonal stance had a successful outcome.
Orlinsky et al. (1994) summarized 55 findings related to the client’s contri-
bution to the therapeutic alliance and found significant relationship in 67%
of the cases. The client’s positive contribution to the therapeutic alliance
was associated with good outcome for therapy lasting 20 to 40 sessions but not
for the short term (i.e., fewer than 20 sessions). They also reported a positive
association between outcome and the client’s total affective response (both
negative and positive) in 50% of 10 findings (not differentiating between
positive and negative affects). When just positive affective responses were
considered, all nine findings in three relevant studies showed significant
associations with favorable outcomes. In other words, when clients respond
with positive feelings during sessions, it is likely an indication that therapy
is proceeding well.

Client Affirmation
Orlinsky et al. (1994) summarized 59 studies and found that client affir-
mation of the therapist had a more consistent association with outcome than
did therapist affirmation of the client (69% vs. 56%). They noted, though,
that client affirmation may be a result of therapeutic progress rather than a
precipitant. Logically, a reciprocal affirmation between client and therapist
should follow. In 78% of 32 findings, reciprocal affirmations were significantly
positive (figures derived primarily from the clients’ or external raters’ process
perspectives). Furthermore, Beutler, Crago, and Arizmendi (1986) found a
positive correlation between outcome and clients’ positive perceptions of
their therapists’ facilitative attitudes (empathy, genuineness, congruence,
nonpossessive warmth, and unconditional positive regard).
Openness Versus Defensiveness
Orlinsky and Howard (1986) described a category called patient self-

relatedness, which refers to people’s way of responding to themselves. Briefly,
it has to do with the ways that people experience their internal ideations and
feelings, become self-aware, evaluate themselves, and monitor their ideas and
feelings. People can be open-minded and flexible in responding, or they can be
guarded and constrained. In the first instance, they are regarded as open and
receptive; in the second, they are typically viewed as defensive. The client’s
capacity to make use of the therapeutic interventions and relationship come
into the picture here. The researchers found that a client’s openness versus
defensiveness in psychotherapy was related to outcome. Better outcomes were
significantly associated with the client’s openness during therapy. In a review
of 45 findings, Orlinsky et al. (1994) noted that 80% of studies showed client
openness to be a positive correlate of therapy outcome. They also noted that
several of these studies had large effect sizes, which can be interpreted as being
indicative of a strong and consistent finding. Orlinsky et al. reported that in
nearly 50 findings that included a look at patient cooperation and patient resis-
tance, 69% of the findings showed significant associations of patient coopera-
tion with favorable outcomes and patient resistance with unfavorable outcomes.
EXPERIENCING
A client’s willingness to experience affect seems essential to success-

ful therapy. However, not every client who wishes to do so will necessarily
be good at it. The capacity for emotional experiencing has emerged as an

important variable in determining whether the client is likely to benefit
from therapy (Greenberg & Pinsof, 1986). Klein, Mathieu-Coughlan, and
Keisler (1986) developed the Experiencing Scale to assess the quality of the
client’s experiencing based on Rogers’s (1954) and Gendlin, Beebe, Cassens,
Klein, and Oberlander’s (1968) client-centered theories. The Experiencing
Scale appears to assess productive client functioning as opposed to a stable
personality trait such as openness. More specifically, the scale was indica-
tive of depth of experiencing and participation in therapy. The researchers
described extensive efforts at training clients in experiencing, empathy, and
communication.
Gendlin (1984) described felt sense as “the client inside us, a kind of
self-response process” (p. 83), and he regarded the process as something that
could be taught to clients through guided focusing (Gendlin, 1996). His studies
on client-centered therapy found that clients high in the ability for work-
ing with inner experience appeared to benefit more from psychotherapy. As
a result of these findings, Gendlin created his focusing method in hopes of
enhancing the experience process for those clients who were not well devel-
oped in their ability to do so. The notion of “training” clients or providing
them with process guidance to make the best use of the therapy process is not
a widespread practice and requires a revised conception of how to proceed in
psychotherapy. When Gendlin started the guiding/teaching method, it was
controversial because it conflicted with the nondirective position of classical
client-centered therapy. Intuitively, it does seem to make a good deal of sense
for clients who need help in developing the capacity to experience because
their progress may be slowed without this skill. Klein et al. (1986) also found
support for the association between high levels of client experiencing and
therapeutic change. Client experiencing has been described as one of the
most substantiated constructs related to outcome in psychotherapy (Todd &
Bohart, 1999).
Expressiveness
In a large review of studies that looked at client expressiveness, Orlinsky

et al. (1994) reported that out of 51 findings, 63% showed a positive associa-
tion with outcome. Similarly, a study by Beutler et al. (1986) revealed that
clients who were open, in touch with their emotions, and able to express
their thoughts and feelings in therapy had a positive prognosis. Butler, Rice,
and Wagstaff (1962) as well as Rice and Wagstaff (1967) found that psycho-
therapy outcomes could be predicted as early as the second session by look-
ing at client expressiveness. Expressive clients had more positive outcomes,
whereas inexpressive clients (characterized as having dull, lifeless ways of
describing self and inner experience) had less favorable outcomes.

Locus of Control
From a humanistic–experiential perspective, having an internal locus

of control is central to psychological health. Each person must take respon-
sibility for one’s actions. There is evidence that suggests that until someone
develops an internal locus of control, the benefits of psychotherapy are lim-
ited. Giacomo and Weissmark (1992) examined the work of 15 therapists.
Specifically, each therapist had one successful case and one unsuccessful case.
The client change measures were internal–external (defined as whether an
individual evaluates an action as a means for affecting the environment or
as a means for being affected by it), reactive–selective (defined as whether an
individual considers oneself capable or not capable of choosing or influenc-
ing a course of action), and unconditional–conditional (defined as whether an
individual evaluates the course of an action as dependent or independent of
the conditions under which the action occurs). An attempt to understand
the differences revealed that successful clients became more internal, more
selective, and more conditional, whereas the unsuccessful cases remained
external, less selective, and less conditional. The researchers noted that the
client’s participation in treatment was significantly related to outcome.
STUDIES ON CLIENT VARIABLES AND OUTCOME SINCE 2000
A Paradigm Shift—The Client’s Perspective
Since the year 2000, a good deal of research on client variables and out-
come has been conducted. One significant change in studying psychotherapy
outcomes has been the attempt to delve more deeply into what clients say
about the process. Looking at therapy from the client’s perspective consti-
tutes a paradigm shift in the field of psychotherapy research. Historically,
research has been more inclined to examine various therapist interventions
and how clients reacted in turn. Actually seeking in-depth data from clients
as to their perceptions about what was helpful or not is not commonplace in
prior research. Rennie (2002) did review a few studies done in the 1980s and
1990s that utilized qualitative methodology, but for the most part, researchers
have not sought client commentary about process and outcome until more
recently. In retrospect, it seems strange that researchers have not delved more
into client factors from the client’s perspective. There seems to have been a
kind of distrust of client input, perhaps reflective of the thinking that clients
would not be accurate in their descriptions because of transference issues or
not speaking the language of therapists. In fact, the term treatment carries
the implication of a client coming in for treatment to be administered by an

expert. Along the same lines, consider how the weight of responsibility shifts
to the therapist when hearing the phrase “A client is under the care of the
therapist.” It does seem important to remind ourselves that from the stand-
point of humanistic therapies, seeking client input is consistent with the
notion of regarding the client as having an organismic valuing tendency or
an ability to know what is right for his or her psychological health (Maslow,
1970). Similarly, Rogers (1961) talked extensively about trusting the wisdom
of the client. Likewise, Combs (1989) stated that the client can, will, and
must move toward health if the way feels open. Bohart and Greaves Wade
(2013) noted the importance of checking in with clients and not making
assumptions as to what the clients are thinking and feeling because they
might interpret what happens in therapy differently than do therapists.
Client Perspectives
Klein and Elliott (2006) researched client accounts of personal change

in process-experiential psychotherapy utilizing a methodologically plural-
istic approach. They interviewed 40 clients (107 interviews) at various
stages of therapy regarding 574 client-described changes. In terms of their
open-coding analysis of posttreatment client-described changes, two pri-
mary categories emerged: Changes Within the Self and Changes in Life
Situation. Self-changes included changes in symptoms and affect, self-
esteem, and awareness of the self, which were organized into the subcatego-
ries of Affective Change, Self-Improvement, and Experiential Processing,
respectively. Changes in Life Situation included the subcategory of General
Life Functioning—in which clients described changes in activity, life status,
and role functioning—and the subcategory of Interpersonal Relationships,
which included changes in the client’s relationships with others and the
world. In addition, clients reported changes in how they perceived the
interaction between the self and the world. Along those same lines, clients
reported a greater sense of energy and improved abilities in their relation-
ships with others. Therapy outcome data revealed a pre–post effect size of
.56 across the four outcome measures, with medium to high effect sizes for
each individual measure administered.
Another study seeking client input about helpful therapeutic events
was done by Fitzpatrick, Janzen, Chamodraka, and Park (2006), who asked
20 clients to identify an early critical incident in therapy that helped estab-
lish their relationship with their therapist. Utilizing qualitative research
methodology, they determined that the incidents were critical because of the
meanings attached to therapist interventions regardless of the type of inter-
vention. When clients identified positive meanings, they responded by being
more open to exploration. The authors reported sample phrases that captured

client meanings, such as “I’m important, I’m the center”; “My therapist can
help me”; “I’m okay”; “I can do this myself too”; and “Now I know what to
do here.” When the clients were asked what they believed had contributed
to the important incident, all clients indicated that their openness to coun-
seling was the key, which confirms research reported earlier in this chapter.
When asked to explain further as to how they were open, clients identi-
fied two different approaches to exploration. One was productive openness
described by clients as exploring thoughts and feelings (disclosing), and the
other was receptive openness (making use of therapist input); both were asso-
ciated with positive feelings that resulted in higher levels of exploration or
more positive feelings. The authors speculated that early in therapy, positive
feelings (liking or bond) and exploration (task-goal)—all key components of
the therapeutic alliance—interact to bring about better outcomes.
To obtain clients’ perspectives as to what they considered a good ther-
apy outcome, Binder, Holgersen, and Nielsen (2010) conducted follow-up
interviews with 10 former clients who had been in therapy anywhere from 1
to 19 years. The interviews were conducted anywhere from 2 to 17 years post-
therapy. Their qualitative interviews revealed four thematic clusters: estab-
lishing new ways of relating to others; less symptomatic distress, or changes
in behavioral patterns contributing to suffering; better self-understanding
and insight; and accepting and valuing oneself. The researchers noted that
from the clients’ point of view, a “good outcome” went way beyond symp-
tom reduction. In fact, this study found that good outcome clients seldom
mentioned symptom reduction per se as a significant outcome. New ways of
relating to others were exemplified by comments such as “I dared go into a
relationship with a man who was good for me,” “. . . more authentic relation-
ships with a smaller number of friends,” “. . . how one shows respect toward
others,” “and to dare to make clear boundaries,” and so forth. In terms of
behavior patterns that used to bring suffering, clients shared such realizations
as “that basic feeling of anxiety, sadness, and sorrow is gone, and I am much
more self-aware; I dare to be visible and fight for issues that I have an interest
in”; “I still go down in the cellar. The difference is that I do not stay there”;
and “. . . what happened there in the therapy room, was something that I
brought with me back to the world outside . . . both the things had to do with
being visible, and the things that had to do with standing up . . . to stand up
in my own life.” Better self-understanding and insight were exemplified by
such comments as “I overreact a lot of times and I think, was this a rational
reaction? No, it was not. I react the way I do, but now I am conscious about
it.” In terms of the category of accepting and valuing oneself—most of the
clients described better self-understanding as an important outcome. A client
shared, “Yes, I really believe that people who need to go to therapy . . . that
what they really need is to get an acceptance of themselves. That they need

to be accepted and to feel that they have value.” Another client with a his-
tory of psychosis indicated that “Now I love myself and I am fond of myself. I
didn’t do that before.” The researchers in this study noted that clients expe-
rienced a personal transformation from suffering to growth.
Heatherington, Constantino, Friedlander, Angus, and Messer (2012)
conducted an ambitious qualitative study to gather in-depth information on
clients’ “during-treatment” perceptions of corrective emotional experiences
in psychotherapy. Data were collected from 76 clients from five sites: three
university training clinics, a community mental health center, and a hospital-
based practice. At the end of the fourth session, clients were asked to respond
to an open-ended transtheoretical questionnaire. Specifically, the question
given by Heatherington et al. was as follows:
Have there been any times since you started the present therapy that you
have become aware of an important or meaningful change (or changes)
in your thinking, feeling, behavior, or relationships? This change may
have occurred in the past four weeks or any time during the present
therapy. Please describe such change (or changes) as fully and vividly as
possible. (p. 166)
The second question attempted to gain information about how the change
came about. Specifically, Heatherington et al. (2012) asked clients, “If yes,
what do you believe took place during or between your therapy sessions that
led to such change (or changes)?” (pp. 166–167). One of the categories that
emerged as deeply informative was new experiential awareness. Heatherington
et al. described findings in this category as follows:
new experiential awareness . . . that a problems does exist (e.g., “I feel
resentment and anger that I was not aware of before”); new awareness of
patterns in interpersonal awareness (e.g., “I never really knew how much
anger scares me and reminds me of people who have hurt me in the past.
That is probably why I just clam up when I am angry. I’d rather make
excuses for other people’s bad behavior than let myself get angry”); and
new awareness of emotions (e.g., “I am more aware of my detachment in
everyday living”). (p. 166)
Further, Heatherington et al. (2012) noted that the shift involved an
uncovering of experience or feelings that clients typically described as having
occurred gradually; client quotes included such statements as “I have become
more aware of how often I blame myself for things and let people walk all over
me” (p. 182). New experiential awareness was the most frequently identified
corrective experience, accounting for approximately 30% to 40% of all mean-
ing units in four of the five samples analyzed. Heatherington et al. interpreted
this to mean than an association with a positive outcome occurred when
clients made “the shift from a state of not knowing to knowing something

that was personally meaningful and related to their presenting problems or
for concerns that arose during treatment” (pp. 181–182).
The second most frequently identified proportion of responses had to do
with those described as new perspectives (more cognitive than experiential).
Example client quotes from Heatherington et al. (2012) include “I felt a shift
in . . . having alternative perspectives about different situations in my life”
and “I think I have become more aware of how much events in the past have
and continue to effect [sic] my life in the present” (p. 182). Heatherington
et al. reported that 73% of all responses in two of the samples, 64% in the
third sample, and nearly 59% in the fourth sample had to do with the first two
categories. The clients in this study indicated that positive therapy changes
meant bringing to awareness previously unacknowledged material and/or the
experience of understanding (whether it be about relationships, or relation-
ships between past and present, or about the self).
Emotional Expression and Experiencing
Better outcomes have been associated with the expression of highly

aroused emotions. Greenberg, Auszra, and Herrmann (2007) did an intensive
analysis of productivity and the degree of in session emotional arousal in four
better outcome clients and four poorer outcome clients. There was no differ-
ence in the intensity of emotional arousal between the two groups; however,
good outcome clients expressed significantly more productive emotion. That
is, they found meaning, connections, and awareness that helped bring about
therapeutic change. Visible emotional arousal and experiencing was a better
predictor than one variable alone. This 2007 study provided support for prior
research (Missirlian, Toukmanian, Warwar, & Greenberg, 2005) showing
that it is important not only to experience emotion but also to reflect on the
emotional arousal to produce client change.
Greenberg et al. (2007) also looked at the relationship of emotional pro-
ductivity, emotional arousal, and outcome in experiential therapy for depression.
They found that the degree of expressed emotional arousal was not predictive of
better or poorer outcomes. Rather, their study revealed that better outcome cli-
ents expressed significantly more productive emotions. This seeming contradic-
tion may be clarified by Greenberg’s (2002) earlier study in which he noted that
to achieve a good outcome, clients may need to accept their feelings, be moved
and informed by them, and transform them when they become maladaptive.
Depth of Experiencing
In a study of 35 clients over 16 to 20 weeks of therapy, Goldman, Greenberg,

and Pos (2005) sought to determine whether the depth of experiencing is

predictive of outcome and whether change in the depth of experiencing is
predictive of outcome. Further, they sought to examine how these variables
fared when compared with the therapeutic alliance as predictive of outcome.
Findings included that the depth of experience on core treatment issues over
the second half of therapy was a significant predictor of positive outcomes
as measured by symptom distress and an increase in self-esteem. Depth of
experience accounted for outcome variance over and above that attributed
to therapeutic alliance.
Therapists use a variety of methods in the helping process, some of
which can be utilized to assist clients needing help in experiencing at a deeper
level. Responding with accurate levels of empathy and using metaphor are
but two examples that can assist clients in deepening their experience of the
therapy process. Becoming skilled in empathy requires that therapists not
only understand a client’s experience but also be able to respond in a way that
the client feels understood. Doing so requires the therapist to have a rich and
readily available affective vocabulary. For example:
Client: I have been feeling low since she left.
Therapist: You are experiencing a difficult time and feeling downhearted
and dejected.
Client: Yes. The word downhearted really fits. It feels like my heart
is way down here. [gestures to the floor]
The response in this example is more likely to capture the client’s experi-
ence and may lead to a richer more meaningful description of the client’s strug-
gle. Some clients have the ability to articulate experiences in rich and vivid ways
that allow for a deeper exploration of their presenting problem. The research
shows that there are clients who do seek treatment but do not have such capaci-
ties. It is in those cases that therapists’ efforts are critical in enabling clients to
describe and experience their life events in a deeper fashion. There are exercises
one can do to increase a client’s affective vocabulary (Welch & Gonzalez, 1999).
For example, therapists can have clients utilize “word ladders” in which they
select an affective word and then generate two or more words depicting more
intensity of feeling followed by two or more words indicative of less intensity.
Take the word mad, for example. More intense descriptions would be provoked
and furious. Less intense descriptions would be irritated and annoyed.
In addition to helping clients develop a rich affective vocabulary to
more adequately capture the nuances of their experiences, encouraging the
use of metaphor can also serve as a means to assist clients in being able to
clarify and deepen their experiences. For example:
Client: Since losing my spouse I am lost. I have never been alone
like this before. I wish I could find the words to describe it.

Therapist: I am trying to form an image of your lostness. Can you pic-
ture your lostness or aloneness in some way that might help
you find the words?
Client: It is like being untethered in space. It’s a frightening
experience.
Images generated through the use of metaphor can serve to deepen the
experience of therapy when words alone fail. Although it may seem that
these examples are more related to the skill of the therapist, the concept
also has to do with client characteristics and outcome. In this case, because
depth of experiencing has been shown to be related to successful outcomes,
it becomes the responsibility of the therapist to help the client develop this
capacity when needed. Holowaty and Paivio (2012) studied 29 clients who
were victims of various complex childhood traumas. Video and audio tapes
of therapy sessions were reviewed in an attempt to identify helpful events.
Clients who were able to identify helpful events were able to do so in a rich
and informative manner and illustrated how depth of experiencing is impor-
tant for therapeutic change. For example, regarding the exploration of child
abuse memories, a client in Holowaty and Paivio’s research study said,
Telling details of the sexual abuse incident and re-experiencing feelings
of fear and shame, and anger toward my brother (perpetrator); this event
was helpful because it made it more real and moved me out of denial so
I didn’t have to cover up for him anymore; I felt empowered and able to
cry and feel supportive of myself. (p. 61)
One of the categories that emerged in Holowaty and Paivio’s (2012)
study was termed Allowing Pain and Grieving and was exemplified by a client
who “admitted feelings of worthlessness and shame. I was angry and ashamed
of my father for my chaotic upbringing where my needs were never met and
I never felt safe” (p. 61); this event was helpful because “I exposed the shame
and guilt and pain; it was a great relief and it caused me to grieve” (p. 61). A
second category was termed Exploring Self-Conflict. A client in Holowaty
and Paivio’s research study identified the helpful event as a
two-chair dialogue with the critical part that sabotages attempts at suc-
cess, and connecting this to shame about my alcoholic family and fear of
showing my true self; this even helped me deal with my negative think-
ing and I don’t have to beat myself up as much; getting out the pain and
humiliation in my family. (p. 61)
Clients further indicated that the expression of intense anger and sad-
ness was helpful, which provides further evidence of the importance of cli-
ents engaging deeply with their emotions. These examples also illustrate the
importance of finding meaning as part of the emotional arousal.

A qualitative study of clients’ perspectives about corrective relational
experiences in therapy was conducted by Knox, Hess, Hill, Burkard, and
Crook-Lyon (2012). The underlying assumption of this study was that the
therapeutic relationship itself provides the source of the corrective experi-
ence. In all, 12 clients participated. Though this study examined the ther-
apeutic relationship, and most of the findings were related to research on
the therapeutic alliance, one important factor reported by the clients was
the fact that they were deeply involved/engaged in the therapeutic process.
Level of experiencing on core themes during the second half of therapy was
a significant predictor of increased self-esteem and reduction of distressing
symptoms. This finding demonstrated that even though some clients may
not begin therapy with the skill for processing emotion, it can be taught or
learned during the course of therapy.
Positive View of Self
Support for the importance of having a positive view of the self can
be found in a study by Halvorsen and Monsen (2007), who studied the pre-
treatment self-image of 233 patients using structural analysis of social behavior.
The patients were classified into four self-image groups (self-attack, self-control,
intermediate attack-control, and self-love). The more disturbed clients with the
self-attacking pattern needed longer treatment (M = 39 sessions) to overcome
their self-devaluating behaviors. The authors contended that the rigid forms of
self-hostility need numerous repetitions of corrective experiences before clients
can move toward more self-acceptance and a more positive view of the self.
There was a change toward a healthier self-image in the overall sample. In their
study, Halvorsen and Monsen found that the group with the largest change was
the hostile, self-attacking group.
Motivation
Zuroff et al. (2007) looked at autonomous motivation for therapy in a

sample of 95 patients with depression. Autonomous motivation was defined
by Zuroff et al. as the “extent to which patients experience participation
in treatment as a freely made choice emanating from themselves” (p. 137).
The patients were randomly assigned to receive 16 sessions of interpersonal
therapy, cognitive behavioral therapy, or pharmacotherapy with clinical
management. Autonomous motivation, therapeutic alliance, and perceived
therapist autonomy support were assessed at Session 3. Autonomous motiva-
tion predicted more strongly the outcome than did the therapeutic alliance.
That is, autonomous motivation predicted a higher probability of achieving
remission and lower posttreatment depression severity across all three forms

of treatment. Patients who perceived their therapists as more supportive of
autonomy reported higher autonomous motivation. An autonomy-supporting
environment is one in which the therapist facilitates the process of internaliz-
ing environmental demands and regulations so that clients can create person-
ally meaningful and freely chosen goals. The researchers noted that therapists
can do this by recognizing others’ unique perspectives, acknowledging their
feelings, refraining from pressuring them, providing as much choice as pos-
sible within the context, and providing meaningful rationales when choice
is not possible.
In addition, it is important to consider that motivation has more than one
dimension. A client may be motivated to come in for help and even express
a genuine wish to change. However, it is also important to realize that want-
ing to change and being ready to change are not the same thing. Being ready
to explore painful feelings requires courage on the client’s part and appropri-
ate support from the therapist. It is one thing to be sitting on the edge of a
swimming pool with feet in the water and quite another thing to actually
jump in. Norcross, Krebs, and Prochaska (2011) conducted a meta-analysis of
39 research investigations examining the association between clients’ readiness
to change prior to the onset of therapy and the eventual outcome of therapy.
They found effect sizes ranging from medium to large, with an overall medium
effect size of d = 0.46. Self-generated motivation (internal motivation) on the
part of the client was indicative of readiness to change, and clients at this stage
were the most likely to benefit from therapy.
Resistance
Another client characteristic related to motivation is resistance. Not

surprisingly, clients who are in treatment not by choice (e.g., mandated) have
poor therapy outcomes. Parhar, Wormith, Derkzen, and Beauregard (2008)
did a meta-analysis of 129 studies of mandated, coerced, and voluntary treat-
ment in reducing rates of recidivism for criminal offenders. Overall, mandated
treatment was found to be ineffective, especially when it was conducted in a
custodial setting. By contrast, voluntary treatment was associated with suc-
cessful therapy outcomes. To gain a better understanding of client resistance,
Beutler, Harwood, Michelson, Song, and Holman (2011) studied the level
of reactance in clients. Reactance was defined as the degree to which clients
interpret external direction as impinging on their freedom. The researchers
hypothesized that clients high in reactance are more likely to manifest higher
levels of resistance when interacting with directive therapists. Their analyses
of 12 studies that examined the relationship of client reactance to the direc-
tiveness of treatment confirmed their hypothesis and found a large effect
size of d = 0.82, which is equivalent to an r of .38. Specifically, clients high

in reactance who worked with therapists lower in directiveness had better
therapy outcomes than did clients high in reactance who worked with more
directive therapists. Furthermore, when clients high in reactance worked
with therapists lower in directiveness, treatment was more effective.
Also, in terms of willingness to engage in the therapy process, it seems
important to recognize that not all “clients” are willing consumers. They
may, for whatever reason, decline to participate at the level necessary to
make change. In such cases, thinking in terms of treatment failure may not
be accurate. The person may just be choosing to not participate, which is
not necessarily treatment failure. If a person chooses not to take an aspirin,
it does not mean the aspirin failed to provide relief. People pressured to seek
psychotherapy find themselves in the underdog position and may through
their behavior say, “You can make me do it, but you can’t make me like it,
and you can’t make me do it right” (P. G. Ossorio, personal communication,
1984). The relationship between clients’ involvement and good outcomes
cannot be overstated.
Client Expectations About Treatment
Educating clients about the nature of therapy, the role of the therapist,
and the client’s role may be more important and useful than previously real-
ized (Swift & Greenberg, 2015). Most training programs and therapists likely
include a brief description of the nature of therapy and the expectations for
each. Indications are that this process should be a more considered one.
Constantino, Glass, Arnkoff, Ametrano, and Smith (2011) conducted
a meta-analysis of 46 studies that looked at the relationship between clients’
treatment expectations and outcome. Their analyses found a small but sig-
nificant effect size (r = .12) between expectations and outcome. Their review
included suggestions for assessing and modifying client expectations in order
to enhance treatment success.
In one illustrative study, Patterson, Uhlin, and Anderson (2008) exam-
ined the pretreatment expectations of 57 clients to determine the relation-
ship between expectations and the strength of the therapeutic alliance.
This study noted the importance of incorporating a more thorough assess-
ment of clients’ expectations at the beginning of therapy. One measure
utilized was the Expectations About Counseling–Brief Form (Tinsley &
Westcot, 1990). This measure included the Personal Commitment Factor,
which looked at clients’ expectations regarding attending counseling more
than a few sessions, the open expression of feelings in session, willingness
to take responsibility for therapy, and commitment to the work of ther-
apy. Following the third session, clients completed the Working Alliance
Inventory (Horvath & Greenberg, 1989), because alliance ratings from

the third session have proven to be reliable predictors of therapy outcome
(Horvath & Bedi, 2002). Their study found that client expectations regard-
ing Personal Commitment predicted the Task, Bond, and Goal dimensions
of the working alliance. In other words, clients who expect to take respon-
sibility for the therapeutic work and make a commitment to therapy were
better able to form a strong working alliance with the therapist. Patterson
et al. also suggested that future researchers focus on expectations about the
commitment needed for therapy as well as expectations about the relation-
ship with the therapist.
Westra, Aviram, Barnes, and Angus (2010) conducted a qualitative
study of client expectations and the effects on process and outcome. They
examined the experiences of nine clients with good outcomes and nine
clients with poor outcomes, all with the diagnosis of generalized anxiety dis-
order. Clients with good outcomes expressed surprise that therapy was a col-
laborative process, that they were free to direct therapy, and that they were
able to be trusting of the process (which included the discovery that working
on painful material could be helpful). In addition, clients described feelings
of surprise that the therapist did not judge them. Furthermore, they expressed
that they actually gained more from therapy than expected. Clients with
poor outcomes did not typically describe these types of experiences. Rather,
they described feelings of disappointment that therapy was not successful,
though in most cases the clients did not blame the therapist. The research-
ers noted the importance for therapists to embody a collaborative, noncoer-
cive approach to clients to best facilitate clients’ active participation in the
therapy process.
Variables closely related to client expectations are those related to
client preferences. Swift, Callahan, and Vollmer (2011) did a meta-analysis
of 35 studies on client preferences regarding role (of client and therapist),
therapist preferences (e.g., advice giving vs. listening), and group versus
individual therapy. Swift et al. found that clients who had their preferred
conditions were significantly (overall effect size was d = 0.31, which is small,
equivalent to r = .15) less likely to end therapy prematurely. The researchers
suggested the importance of monitoring client preferences, especially if it
seems like the client is struggling to engage in the process (see also Swift &
Greenberg, 2015).
Collaboration
Tryon and Winograd (2001) conducted a meta-analysis of 15 recent

studies published from 2000 through 2009 with a total sample size of 1,302
and looked at the relationship of treatment outcome to goal consensus and
collaboration. They found ample evidence that better outcomes are arrived

at when the patient and therapist agree not only on the goals but also on
the process involved in reaching these goals. Tryon and Winograd’s study
included a number of factors related to goals and collaboration: (a) patient–
therapist agreement on goals; (b) the extent to which a therapist explains the
nature and expectations of therapy, and the patient’s understanding of the infor-
mation; (c) the extent to which the goals are discussed, and the patient’s belief
that goals are clearly specified; (d) the patient’s commitment to goals; and
(e) patient–therapist congruence on the origin of the patient’s problem, and
congruence on who or what is responsible for problem solution (pp. 385–386).
They concluded that it is best to begin working on the client’s problems only
after both patient and therapist have agreed on the treatment goals and the
ways they will work together to reach those goals. They also cautioned ther-
apists to be mindful of not pushing the therapist’s agenda. Rather, therapists
should listen to what clients say and should formulate interventions with
that input and understanding in mind. Furthermore, they recommended
that therapists encourage client contribution throughout psychotherapy
by seeking patient feedback, insights, reflections, and elaborations. Also,
they suggested to have regular check-ins with the client about current moti-
vation to change and social support and to give them feedback about their
progress.
Even though we may accept the notion that collaboration is the most
useful fashion to proceed in psychotherapy, challenging clients may in subtle
ways influence us to assume a less collaborative position. One suggestion for
therapists is to become conscious of one’s own self-talk. For example, if we find
ourselves saying things such as “If I could just get my client to . . . ,” “If I could
just convince my client of . . . ,” or “If I could just get my client to see . . .” or
thinking in terms of “persuading,” then we as therapists have likely moved
to controlling and directing, which is not likely to be helpful (Combs &
Gonzalez, 1994). The frustration that can come when clients do not seem to
be progressing can result in the therapist taking too much of the responsibil-
ity for the process and losing the collaborative component as well as losing
trust in the clients’ process of change.
Attachment Style
Being able to understand a client’s attachment style is an important

dimension of therapy, perhaps even more so from a person-centered perspec-
tive. Logic would dictate that deeper levels of empathy are made possible
by having a deeper level of understanding of a client’s phenomenology, of
which attachment history is considered of great significance. Levy, Ellison,
Scott, and Bernecker (2011) described three of the four more commonly
recognized attachment styles. Securely attached persons have a positive view

of self and others; preoccupied/anxious attached individuals have a negative
view of self and a positive view of others; and avoidant (fearful/dismissive)
individuals have a positive view of self and a negative view of others. Levy
et al. conducted a meta-analysis of 19 studies and found a significant posi-
tive correlation between global assessments of clients’ with a secure attach-
ment style and outcome (r = .18). However, the data revealed a significant
negative correlation between an anxious attachment style and outcome
(r = .224). Sauer, Anderson, Gormley, Richmond, and Preacco (2010)
looked at the relationships between client attachment style, working alli-
ance, and therapeutic progress. Ninety-five clients from two university
training clinics completed adult attachment measures—attachment to
therapist and working alliance—immediately prior to the third counsel-
ing session with trainees. A standardized measure of progress in therapy
was administered at intake, third counseling session, and at termination.
The researchers found that stronger working alliances and secure attach-
ment to the therapist were significantly associated with positive outcomes
(defined as significant reduction in client distress). Clients high in attach-
ment anxiety were associated with higher ratings of distress ratings at the
outset of therapy. Sauer et al. found that secure attachment to the therapist
had more predictive value to treatment progress than did global measures
of secure attachment.
In a study of 117 psychotherapy patients, Saypol and Farber (2010)
found that clients with a secure attachment style were associated with
higher levels of self-disclosure as well as positive feelings about disclosure.
However, fearful attachment style was associated with lower levels of self-
disclosure and negative feelings about disclosure. The authors stated that the
most novel finding of the study was that there was an association between
attachment style to one’s therapist and the feelings experienced before and
after disclosure. Positive associations were found between fearful attachment
and unpleasant feelings both before and after disclosure. A fearful attach-
ment style is characterized by a negative model of self and other; individu-
als with this style tend to be avoidant of others and, as suggested by this
study, tend to be more fearful in disclosing to their therapist. Because they
view themselves as unworthy of responsiveness from others, these clients are
seemingly more likely to experience emotions such as shame, vulnerability,
and anxiety. Also, the amount of exploration and depth of session mate-
rial was predicted by clients’ secure attachment to the therapist (Saypol &
Farber, 2010). Though outside the scope of this chapter, which focuses on
client’s contribution to outcome, one challenge for each of us as therapists
is to consider the following questions: What is our own attachment style?
Furthermore, how might it influence the outcome of therapy as our style
interacts with that of the client?

Client Involvement
The importance of client involvement to successful outcome has been

clearly demonstrated in empirical research. Hence, the need for therapists to
foster and maintain client involvement in the process is also clear. Beginning
with our initial contact with clients, our presentation about how the pro-
cess works is critical. Many clients are likely to see therapists as experts with
the answers to their problems. Therefore, for example, in our explanation to
the client about our theoretical orientation, we need to be mindful about how
we present the process. If the description places the therapist in the role of the
expert, then the level of client involvement is likely to be affected. Regardless
of theoretical orientation, as we familiarize clients with the therapeutic process,
our description needs to clearly demonstrate a commitment to therapy as a
process of collaboration, working together to explore, clarify, and move toward
client desired change. Therapists then need to follow through by maintaining
a collaborative process—that is, not providing answers to all the presenting
problems but rather working together to understand problems and to discover
solutions. The client can potentially learn early on that therapy is collaborative
and will require a thoughtful investment for the process to work. Hopefully, by
establishing client responsibility at the beginning of therapy, clients will come
to session knowing that the therapy material has to originate from them.
In addition, Bohart and Tallman (1999) made the point that true collabo-
ration goes beyond the client merely participating in the therapist’s agenda.
They contended that a truly collaborative model involves, among other things,
the therapist carefully listening to the client for client-generated solutions and
encouraging the client to more fully explain his or her point of view. This
implies a belief and respect on the part of the therapist for the client’s capacities
for self-healing and problem solving. One technique that works with a collab-
orative model, Ask the Expert (Welch & Gonzalez, 1999), is illustrated in the
following example, in which a 35-year-old man expresses dismay that he still
feels intimidated by and subservient to his disapproving father.
Example:
Client: I wish I could figure out why I don’t stand up to my father.
I get so angry with myself for letting him treat me poorly. I
keep telling myself that I need to stand up for myself. I just
can’t do it. I can’t figure it out. I just don’t get it. Why do you
think I won’t stand up to my father?
Therapist: It sounds like you have thought about this a great deal. I
wonder what you have come up with so far.

Client: Nothing. That is why I am asking you.
Therapist: It sounds like you need an expert who can answer your
question. Fortunately, we have someone with expertise in
that area right in this office. I will have that person come in
momentarily. What exactly did you want to ask him?
Client: I want to ask why I don’t stand up to my father.
Therapist: Okay. Let’s switch seats for a moment. You are the expert,
and I will ask the question. Why does someone not stand up
to one’s father?
Client: Uh. Well, maybe I have an idea. Hmmm. Well, I can think
of a couple of reasons.
Therapist: So, already you are coming up with some thoughts that
might help you answer your question.
Client: Yes, but I am not sure I can trust myself. What this brings up
is how much I doubt myself, how unsure I am about whether
or not I am worth much. I realize that I feel disapproved of by
my father. I feel like a scolded kid whenever I am around him.
In this example, the therapist is not giving in to the temptation to
answer or solve the client’s struggle because of a belief in the client’s capac-
ity and inner guidance system. Rather, the attempt is to help the client
develop or enhance that capacity by giving the client a chance to practice
during the course of therapy. If a client lacks confidence and experience
in making difficult decisions, he or she may need some additional support
and practice during therapy. The client is more likely to feel empowered
by discovering answers to confusing problems. The collaborative position
requires that the therapist truly believe in the client’s self-healing capaci-
ties. Consequently, client-generated solutions need to be explored, under-
stood, and respected.
New Awareness
The gradual acquisition of greater levels of awareness found and

described in Heatherington et al.’s (2012) study is consistent with humanis-
tic theory. New awarenesses and discovery of meaning come about through
a process of increasing differentiation of experience. Usually this occurs as
a consequence of a series of slow steps in which one differentiation is fol-
lowed by another and another until the new event is learned or its per-
sonal meaning discovered. This is true even in those instances in which an
insight seems to come about in a sudden flash of recognition. Even in such
instances, however, what appears to be a sudden flash of meaning usually

turns out on closer examination to be the final differentiation in a series
of previous, almost imperceptible stages leading to the final denouement.
This is somewhat like finding the key piece in a jigsaw puzzle that makes all
the surrounding parts comprehensible. Without the discoveries preceding
it, finding the key piece would have been of little or no consequence. Its
extraordinary value depends on the hard work that went before. According
to Combs and Gonzalez (1994), the same is true with personal meaning:
The fruit comes only when the ground has been plowed, the seed has been
planted, and conditions favorable for growth have been established (p. 87).
An implication for therapists is the importance of being patient and being
with the client wherever that may be.
Consider the case of a 45-year-old man still hurting over his divorce
of 12 years ago. Also, his most recent girlfriend of 3 years has made gestures
toward ending their relationship. He was in obvious pain and distress. In the
initial session, the client expressed the following:
Client: My problem is that I need to learn how to trust. Since my
divorce, I have not been able to find a good relationship. Do
you offer classes on how to trust or do you have any books I
can read on how to trust?
Therapist: It sounds like you have suffered a good bit over the past
12 years. And, it sounds like you really would like to be close
to someone again, but the thought of being hurt again has
been too much, too scary.
Client: Well, I guess that’s true. I haven’t really been thinking of it
in those terms. I thought I had forgotten how to trust. It has
been so long since I have had a trusting relationship. So,
what do you think I should do?
Therapist: You are asking an important question. What comes to mind
when you think what you might need or want to do?
After a few sessions of therapy, the client came to this awareness:
Client: I now realize that I do know how to trust. It is more a matter
of will I trust. Will I take a chance of getting hurt again? Now
I realize that keeping women at arm’s length was preventing
me from forming a deep relationship. Before, I thought it was
them I could not trust. Now I know my fear of further pain
is the problem. And, I had my doubts about my value as a
person. I thought maybe I was not good enough and that is
why my wife wanted a divorce.
Therapist: It sounds like you have learned a lot about yourself and it
has been empowering. You are starting to find some answers
about how to move forward with your life.

Client: As I get to know myself better, I don’t feel so much like a
victim. I am starting to feel like I am a good person and
there might be someone who would like to be in a relation-
ship with me. I have to believe in myself and take a chance
on love. Of course I know how to trust! Before, I was a bit
frustrated that you would not give me some advice or tips
on relationships. Now I realize I had to face myself, my own
pain, and come to terms with what the real problem has
been. I was looking for answers outside myself instead of
within myself.
Although it is important for therapists to assist clients in the quickest
way possible, and it is difficult to see clients in pain, it is also necessary to
not lose sight of the goals, purposes, and processes they are engaged in. In
the age of managed care, the therapist may feel the pressure to move too
quickly. Also, clients themselves often feel anxious to find solutions to their
problems and may put pressure on the therapist to speed the process up. If the
therapist feels anxious and pressured, then he or she may be too distracted to
help the client and can succumb to the temptation and find oneself directing
and controlling the session—behaviors that are associated with less favorable
outcomes. At such times, it is important for the therapist to enhance the cli-
ent’s resourcefulness by relying on the client for suggestions or possible new
directions in therapy.
Our understanding of the relationship of client variables to outcome has

increased tremendously over the past 60 years but even more so in the past
dozen years or so. The most notable shift in client variable research and out-
come has been the emergence of qualitative data to study the therapy process
from the client’s perspective. This shift represents an important evolutionary
step in how best to study therapy and outcome processes. Bohart and Greaves
Wade (2013) made the point that clients are active coconstructors of therapy.
Hence, research will be limited if we approach it unidirectionally, that is to
say, looking only at therapist-to-client influence. We can say from the review
in this current chapter that clients’ degree and depth of participation con-
tinue to be perhaps the most powerful predictors of outcome. Therefore, it is
important for therapists to help clients look inward, experience and describe
feelings more fully, and perhaps gain a sense of responsibility for their life.
Recommended methods of gathering more comprehensive therapist–client
interactive data include session-by-session feedback, tape-assisted recall,
and ongoing diaries (Bohart & Greaves Wade, 2013). Finally, although our

understanding of client variables that affect outcomes has improved dramati-
cally, the actual mechanisms of change are not well understood, and further
research is needed in this area.
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VI
Analysis and Synthesis
15
TOWARD A RESEARCH-BASED
INTEGRATION OF OPTIMAL
PRACTICES OF HUMANISTIC
PSYCHOTHERAPIES
DAVID J. CAIN
The research base of humanistic psychotherapies has burgeoned in

the 13 years since the first edition of Humanistic Psychotherapies: Handbook
of Research and Practice was published in 2002. It is now substantial and
compelling (Angus, Watson, Elliott, Schneider, & Timulak, 2015; Elliott,
Greenberg, Watson, Timulak, & Freire, 2013). In recent decades, an increas-
ing number of humanistic therapists have integrated the findings of sound
quantitative and qualitative research into practice, thereby providing more
optimal therapy for clients. The accumulative research evidence is now ade-
quate to propose an integrated model of humanistic practice grounded in
well-established evidence-based practice. This evidence includes quantita-
tive and qualitative research, case studies, change-process research, efficacy
and effectiveness research, and randomized controlled trials, as well as estab-
lished clinical experience and wisdom that have stood the test of time.
http://dx.doi.org/10.1037/14775-016
Humanistic Psychotherapies: Handbook of Research and Practice, Second Edition, D. J. Cain, K. Keenan,
and S. Rubin (Editors)
485
The model proposed here builds on and expands an earlier synthesis of
mine (Cain, 2010) and another articulated by Bohart, O’Hara, and Leitner
(2004). The new synthesis attempts to bring together the best of what we know
so far, although it is still a tentative statement that I hope will be developed
further over time. My goal here is to identify the core premises of an optimal
practice of humanistic psychotherapy that provides guidelines for practice.
The proposed integration identifies the major humanistic variables that
affect the effective processes and outcome of humanistic psychotherapies. The
review covers research on humanistic psychotherapies over the past 75 years,
with an emphasis on those bodies of research that have been most compelling
over time. The proposed premises interweave therapist and client variables,
interactive variables, and guidelines regarding on what therapists should focus
to maximize the effects of therapy. It is hoped that the proposed model will
have wider applications in the larger field of psychotherapy, especially because
it has moved increasingly toward integrative models of practice.
CLIENT DISTRESS AND READINESS FOR CHANGE
Premise 1: The client is sufficiently distressed in an area of personally sig-

nificant relevance, has a desire for help, and willingly seeks professional
assistance in the alleviation of problems.
Experienced Distress
When clients initially contact a therapist for assistance, it is usually at a

point at which they feel unable to address effectively some problematic aspects
of their lives using their current resources and coping–adaptive mechanisms.
Clients’ current level of distress is usually a key impetus in their decision to
seek a therapist, because they hope to feel and function better. Clients’ level
of involvement and participation in therapy are often related to the subjec-
tive level and nature of their distress.
Most people do not seek psychotherapy unless their level of psychologi-
cal distress is intolerable or at least unacceptable, unless required or coerced
into doing do by the courts, parents, or spouses. Often such clients, when
asked about what they would like help with, respond with something such
as, “I’m here because X wants me to get help.” As Rogers (1961) contended,
experiencing anxiety or incongruence may be an adequate reason for some
people to enter or continue therapy and to motivate change. However, most
people tolerate varying levels of psychological discomfort on their own with-
out seeking therapeutic assistance. Moreover, when their level of discomfort
diminishes to a tolerable level, many clients drop out of therapy, sometimes
486 david j. cain

after one or a few sessions. Clearly, many people who might enter or continue
in therapy will not do so unless they are sufficiently troubled, desirous of
change, and willing to seek assistance.
The experience of being sufficiently distressed reflects clients’ subjective
sense that their problems, however defined, are no longer tolerable and are
interfering with their functioning or quality of life to an unacceptable degree.
The level of psychic discomfort will vary, but it will be characterized by a strong
desire to alleviate stress in an area deemed important enough (e.g., alleviating
depression) to seek help. This is often noticeable in the first session, when
clients have a strong need to get it out and tell their troublesome stories to
relieve some of the stress they are experiencing. Furthermore, the client cur-
rently feels unable to deal with distress alone and experiences a sense of urgency,
ranging from modest to desperate, for relief. When a person recognizes a need
for assistance, has a desire for assistance, and willingly seeks and accepts help,
he or she is likely to be receptive to initiating and continuing psychotherapy.
Research
The dropout rate for clients varies from about 20% to as high as 67%
(e.g., Bohart & Wade, 2013; Clarkin & Levy, 2004), and the modal number
of sessions attended by clients is one (Miller, Duncan, & Hubble, 1997). In a
recent review of the literature on early termination, among the factors identi-
fied by Bohart and Wade (2013) were low motivation, an expectation that
therapy would be helpful more rapidly than it was, and that clients made less
progress than anticipated and felt disappointment in their therapists or with
the alliance. Perhaps most important, “unilateral terminators were more likely
to see their distress as lower when they terminated while their therapists were
more likely to see them as unchanged” (Bohart & Wade, 2013, p. 223).
Client Readiness for Change
Some clients come to therapy highly motivated and receptive to partici-

pation and change, and others have misgivings about whether they even have
problems or need or want professional help. Sometimes they initiate therapy
at the urging of someone else, or they may be sent for therapy by a fam-
ily member, the courts, or even their employers. Consequently, such clients
often start therapy with ambivalence about whether they even want to be
there and, as a result, participate hesitantly. Clearly, clients’ desire and readi-
ness for change is a factor in the quality of their participation. Accordingly,
research and clinical experience have shown that clients who are mandated
for therapy and whose motivation is from an external source do not fare as
well as clients whose motivation is internal.
toward a research-based integration of optimal practices 487

There is a wise adage in the field of psychotherapy that suggests that
therapists start where the client is. Although therapists may assume that,
because clients have initiated psychotherapy or at least attend an initial ses-
sion, they are receptive to and ready for change, this may or may not be
the case. Although most clients want the benefits of change and may even
express desire for change, they may not be ready to engage in the processes
and efforts required for change. Readiness to change implies a willingness to
look at oneself and address one’s limitations, an often daunting endeavor.
Therefore, therapists need to assess where clients are in their current state of
mind as it relates to their receptivity for change.
Research
As Norcross, Krebs, and Prochaska (2011) noted, the client’s readiness

for therapy may range from (a) precontemplative—failure to recognize that a
problem exists and no intention to change behavior—to (b) contemplative—
recognizing a problem but not ready to take action—to (c) preparation for
action—showing readiness for change and intent to take action—to (d) action—
commitment to do what is necessary to alleviate problems. Norcross et al.’s
research found a clinically significant effect size (d = 0.46) between client
readiness to change and therapy outcome. This means that therapists should
note clients’ current state of readiness and respond to it accordingly in an
attempt to engage them actively in assessing and increasing their desire for
change. Therapists need to engage in a dialogue with clients about their current
ambivalence about therapy. Ideally, this is done in a manner that encourages
clients to sort through their conflicting feelings and make a decision about
whether therapy has anything to offer them.
When clients are ambivalent about change, therapists may find it help-
ful to engage in motivational interviewing with them. Rollnick and Miller
(1995) defined motivational interviewing as “a collaborative, person-centered
form of guiding to elicit and strengthen motivation for change” (p. 325).
Motivational interviewing focuses strongly on enabling clients to identify,
reflect on, and resolve ambivalence about therapy and changing their behavior.
Consistent with humanistic values, it strives to enable clients to locate their
internal motivation for change. Research on motivational interviewing has
indicated that it has constructive effects on a number of problems, including
smoking, diet, exercise, and managing chronic disease, as reported by Smith
and Williams (2013). Elliott et al. (2013) reported an overall mean effect size
of .32 in 119 controlled and comparative studies of motivational interview-
ing for a variety of habitual self-damaging behaviors, especially substance
abuse. This research seems to suggest that clients who are not sufficiently
distressed, and therefore inadequately motivated to participate in therapy,
488 david j. cain

can be helped to locate their intrinsic motivation for change by reassessing
the personal impact of their problems.
BEING PRESENT AND ENGAGED
Premise 2: The therapist is consistently present and actively engaged in

all aspects of the therapeutic process.
Clients initially come to therapy in various vulnerable states—anxious,
depressed, uncertain, insecure, experiencing low self-esteem—and wonder
whether the therapist can help them. In this delicate state, therapists’ full pres-
ence is a vital factor in their initial contact with clients (Geller & Greenberg,
2012). The client becomes the center of the therapist’s world.
Effective therapy starts with a therapist who is thoroughly present and
focused. It is enhanced to the degree that the therapist remains so from moment
to moment in each session throughout the course of therapy. An essential com-
mitment of the humanistic therapist is to be fully attentive to and immersed in
the person, experience, and worldview of the client and the client’s expressed
concerns. By being present, therapists fully bring who they are and their dis-
tinctive qualities to engage intently with the client and take in the client’s
entire being. The therapist is receptive and attuned to whatever the client
addresses and is responsive to the client’s manner of communication, including
verbal, nonverbal, affective, and body language. Presence lends power to what-
ever the therapist does. The therapist’s presence is also likely to affect positively
the client’s quality of presence and contact with self and with the therapist.
When fully present, therapists bring a sustained, mindful, and focused
attention to their clients. They make powerful contact by immersing them-
selves in their clients’ worlds and engaging with their clients in meaningful
encounters. They are fully and transparently themselves in the moment and
without any agenda except to be with and receive their clients, thereby cre-
ating a sense of safety that enables clients to disclose themselves more fully.
When present, the therapist indwells the client’s world, is for the client, and is
with the client as a separate self who is willing to engage in an I–Thou encoun-
ter (Moustakas, 1995). Therapists who are fully present with their clients
often respond spontaneously, drawing on creative aspects of themselves that
have therapeutic effects on their clients. Carl Rogers (as cited in M. Baldwin,
1987) commented about the therapeutic effects of his own presence as follows:
I find that when I am the closest to my inner, intuitive self—when per-
haps I am in touch with the unknown in me—when perhaps I am in a
slightly altered state of consciousness in the relationship, then whatever
I do seems to be full of healing. Then simply my presence is releasing and
helpful. (p. 50)

When therapists are present in the manner described by Rogers, clients are
often drawn into moments of fully engaged and present living with their
therapists, an experience that is gratifying, meaningful, hopeful, instructive,
and sometimes transformative. In such moments, clients become aware that
the quality of their lives is enhanced by living fully in the moment, and they
are able to imagine the possibility of being more authentically present in their
relationships with others.
Clients are usually aware of how present their therapists are with them,
just as most of us are aware of how attentive and interested others are when
we converse with them. Therapists, too, are aware of whether they are going
through the motions of acting interested versus actually being invested in
their clients. Therapist presence implies that the therapist is willing to be
fully open to and affected by the client.
Presence is often communicated nonverbally through body language
(e.g., leaning forward, nodding the head), facial expression (e.g., quality of
eye contact, concerned look), vocal tone (e.g., a tone that fits the client’s
emotional expression), and nonverbal communication (e.g., mmm-hmm).
Clients often experience such attention as affirming. Furthermore, therapists’
full immersion in the person of the client and the client’s immediate experi-
ence enables them to make more sensitive and effective responses because
they are so highly attuned.
Presence Research
In recent years, evidence has been generated regarding the impact and
effectiveness of therapist presence. In an unpublished qualitative study of pres-
ence, Pemberton (1977, as cited in Geller & Greenberg, 2012) concluded that
therapists who had high levels of this quality also had awareness, acceptance,
and appreciation of who they were in relationships, were attuned to the present
moment (as opposed to focusing on the past or future), were accepting of imme-
diate experience, and were transparent and personal in their manner of sharing.
Therapists with strong presence were committed both to being themselves and
to being with their clients. They were focused, receptive to their clients’ selves,
and experiencing in an empathic and accepting manner. Other elements of
therapist presence included a sense of aliveness and integration that resulted
in the therapist being centered, authentic, clear, autonomous, and purposeful.
Fraelich (1989, as cited in Geller & Greenberg, 2012), in another
unpublished study, interviewed six therapists about the concept of presence
in a phenomenological study. He identified four themes: (a) immersion in the
moment, (b) spontaneous presence, (c) openness, and (d) living on the cut-
ting edge. Fraelich defined presence as “an intense and richly lived moment”
(Geller & Greenberg, 2012, p. 40), speculating that it contributed to a good
490 david j. cain

outcome in existential psychotherapy. Phelon (2004) studied healing pres-
ence with multiple methodologies, finding that it was related to the therapist’s
commitment to ongoing growth and integration, spiritual practice, quality of
awareness, and quality of alliance between therapist and client.
Geller and Greenberg (2012) did a qualitative study in which they inter-
viewed seven master therapists who were proponents of presence. Therapeutic
presence had three aspects: (a) a pretherapy preparation for presence, (b) the
processes of presence, and (c) the in-session experiences of presence. They
concluded that therapeutic presence “is a complex interplay of therapeutic
skill and experience guided by the underlying intention and experience of
fully being in the moment and meeting that experience with the depth of
one’s being” (Geller & Greenberg, 2012, p. 42).
Geller and Greenberg (2012) developed the Therapeutic Presence
Inventory with versions rated by both therapists and clients. Face validity,
construct validity, and reliability were good. Research showed that, when
clients experienced their therapists as present during a session, they reported
positive change, regardless of the therapist’s theoretical orientation. In addi-
tion, clients rated the therapeutic alliance as stronger when therapists were
rated as present. However, therapists’ ratings of their level of presence was
not related to client-rated session outcome or to therapeutic alliance. Thus,
it is the clients who need to experience the therapist as present for them to
perceive the relationship and session in a positive manner.
Presence-related research by Elliott (1985) suggested that effective ther-
apists focused on client problems, paid attention to affect, helped clients focus
their awareness and become more involved, and maintained personal contact.
Being Engaged
Therapist presence and engagement are intimately related and especially

important during the initial phases of therapy as the client is getting a sense
of the therapist. Clients’ role engagement reflects their personal involvement
in the therapeutic process. Similarly, therapist role engagement (as opposed
to detachment) reflects the therapist’s intent participation in therapy. When
therapists are engaged, they show active interest and involvement, thereby pro-
moting therapeutic processes. Such engagement has a reciprocal effect because
it increases client engagement with the therapist and the therapeutic processes.
Whereas presence implies immersion, engagement implies active participation.
Engagement Research
Therapist engagement showed a positive relationship to outcome in

57% of the study results (Sachse & Elliott, 2002). Orlinsky, Grawe, and Parks

(1994) summarized 54 findings regarding client role engagement. Of the
54 findings, 65% showed a significant positive association with outcome, as
did 92% of findings from the therapist’s process perspective. Clients’ percep-
tion of therapist role engagement (vs. detachment) in 13 studies was related
to good outcome 78% of the time (Orlinsky et al., 1994).
BEING EMPATHIC
Premise 3: The therapist understands the subjective reality of the client

and empathically communicates that understanding to the client.
If there is anything close to a universal desire in people, it is to be under-
stood and accepted as they are. Consistent empathic attunement remains the
bedrock of all psychotherapies, especially humanistic approaches. Therapist
empathy is foundational for developing a therapeutic alliance with clients,
catalyzing client interpersonal and intrapersonal learning, and achieving
good outcomes. Rogers’s (1961) greatest contribution to the field of psycho-
therapy is that he taught therapists to listen, to enter the client’s world and
communicate that understanding for the client’s reflection. Empathy sets in
motion a process whereby clients come to see themselves and their world in
fresh ways that open possibilities for improved functioning and more satisfying
ways of living.
Attuned Listening
Attentive, silent, and patient listening by itself is often therapeutic to

clients because it gives them time to tell their story and experience some relief
from the stress related to their problems. Clients often state, “I need to get
this out” or “I need to get this off my chest,” and this is often best achieved by
simple attentive and sensitive listening alone.
The present and highly focused therapist grasps the client’s communica-
tion on multiple levels, including vocal tone, facial expression, body language,
distinctive language, emotional expression, and tacit messages. This therapeu-
tic endeavor implies entering another’s world so completely as to have a sense
of what it is like to be the other.
Although clients often experience just being listened to as empathic,
the therapist’s understanding needs to be verbally articulated because it can be
perceived and confirmed by the client only if what the therapist communicates
resonates with the client’s reality. When therapists attempt to grasp and com-
municate their clients’ subjective realities, both therapist and client engage
in a mutual process of refinement of the client’s experience that typically pro-
ceeds until the client senses and confirms the truthfulness or “rightness” of the
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understanding. In this sense, the process is one of collaborative empathy in
which the client’s truth is cocreated.
Relational Benefits of Empathy
First and primary, empathy creates a sanctuary that provides safety for
clients to be and explore themselves. Empathy is inherently nonjudgmental
because it addresses what is, not what should be. When heard without evalu-
ation, clients feel safe to disclose troublesome aspects of themselves openly
and nondefensively. Feeling understood also helps clients develop a close and
trusting bond with their therapists. When clients feel seen and heard, they
often experience mutual warmth and liking, feeling respected and valued,
and a sense of “we-ness” as they engage with their therapist.
Empathy, the Self, and the Process of Change
Michael Mahoney (1991), author of Human Change Processes, astutely

noted that “all psychotherapies are psychotherapies of the self ” (p. 235). The
self is central to what and how things are perceived because experiences are
viewed primarily in relation to one’s personal existence.
Therapist empathy has numerous and far-reaching effects on intrapersonal
learning. As clients are accurately heard by their therapist, they learn to reflect
on their experience and engage in self-exploration that often leads to self-
discovery, self-understanding, altered views of the self, and increased congruence
or cohesion in the way the self is experienced. Empathy facilitates self-definition
by enabling clients to achieve greater clarity about who they are, as opposed to
who they thought they were. As clients come to see themselves in new ways,
they are more likely to act in a manner consistent with these revised views.
Research
More than 70 years of research has consistently demonstrated that ther-

apist empathy is the most potent predictor of client progress in therapy and
that it is an essential component of successful therapy in every therapeutic
modality. In both qualitative and quantitative research, feeling understood is
one of the primary experiences clients identify as being helpful. Angus et al.
(2015) summarized recent research on empathy as follows:
Therapists’ empathy was associated with significant improvement in
attachment insecurity and significant decreases in self-criticism, neglect-
ful, and controlling behaviors toward the self at the end of therapy and
in turn, these positive changes were significantly associated with good
outcome in brief humanistic treatments of depression. (p. 29)

In recent years, there has been a revival of interest in the constructive
impact of therapist empathy (Bohart & Greenberg, 1997). Watson (2002)
reviewed the research on therapist empathy and found that (a) research has
consistently demonstrated that therapist empathy is the strongest predic-
tor of client progress in therapy and is an essential component of successful
therapy in every therapeutic modality, (b) no study has shown a negative
relationship between empathy and outcome, and (c) client ratings of thera-
pist empathy are stronger predictors of successful outcome than the ratings of
external judges or therapists.
In a research review of 47 studies and 190 tests of the relationship
between therapist empathy and outcome, Greenberg, Watson, Elliott, and
Bohart (2001) reported that therapist empathy had a medium effect size that
accounted for about 10% of outcome variance. A sobering piece of evidence
is that lack of therapist understanding was consistently associated with nega-
tive outcomes (Mohr, 1995).
Sachse and Elliott’s (2002) microprocess research showed that therapist
empathic responses might deepen, maintain, or flatten client experiential
processing and self-exploration. Furthermore, he showed that most clients do
little experiential processing on their own and do not deepen their processing
unless the therapist provides deepening empathic responses.
A qualitative study by Grote (2005) on the experience of feeling really
understood in psychotherapy found that this experience involved clients’
feeling (a) safe, (b) accepted, (c) relieved, (d) validated, (e) heard, (f) seen
and known, (g) engaged with an active coparticipant, (h) a sense of inti-
macy with the therapist, (i) a surprised sense of awe at the discovery of a
core truth or new way of looking at a situation, (j) more self-acceptance, and
(k) engaged with a compassionate, genuine “other.” In short, multiple atti-
tudes, qualities, skills, and behaviors contribute to the client’s sense of being
heard and seen accurately, some of which differ from what most therapists
conceive as empathic understanding. Similarly, Bachelor’s (1988) research
demonstrated that what clients perceive to be empathic varies from cli-
ent to client and does not always correspond to what therapists consider
an empathic response. In other words, to be maximally effective, empathy
needs to be individualized.
In a study of empathy research that reviewed 59 samples and 3,599 cli-
ents, Elliott, Bohart, Watson, and Greenberg (2011) concluded that empathy
was a moderately strong predictor of therapy outcome, with a mean weighted
r of .31. Client and observer measures of therapist empathy were better predic-
tors of outcome than therapists’ own perceptions of empathic accuracy.
Research on therapist listening, a component of empathy, has shown that
it is highly rated by clients as helpful, especially when clients are struggling
with suicidal impulses (Cooper, 2008, p. 144). Conversely, Paulson, Everall,
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and Stuart (2001) found that the therapist’s failure to listen, as perceived by
clients, was extremely unhelpful or hindering. The desire to hear one’s clients,
enter into their experiential worlds, and communicate that understanding is
almost invariably helpful and rarely, if ever, harmful, whereas failure to do so
has adverse effects.
BEING ACCEPTING, UNCONDITIONAL

IN REGARD, AND AFFIRMING
Premise 4: Therapists consistently and predominantly experience and

communicate positive regard and affirmation for their clients.
Being accepted and valued for who one is is likely a universal need
or desire. Maslow (1987) identified love and belonging as fundamental and
basic needs that, if not met, lead to loneliness, alienation, ostracism, and
a questioning of one’s worth. People will go to great extremes to manage
their public image in the hope of being perceived in a positive manner. For
children, few experiences are more important than feeling securely loved
or, conversely, are more damaging or painful than disapproval, rejection, or
abuse by their parents, peers, or significant others. Long ago, Adler (1927)
recognized how important it was for children (and adults) to have a sense of
belonging and a place of value in their families and social groups. Humans
are essentially social beings whose well-being depends largely on their feel-
ing affiliated with, securely attached to, and loved by at least a few significant
people in their lives.
The therapist’s unconditional positive regard, acceptance, nonpossessive
warmth, lack of judgment, and affirming attitudes and responses have a power-
ful impact on the client’s view of self and sense of worth. Mearns and Thorne
(2007) stated their belief that
the counselor who holds this attitude [unconditional positive regard]
deeply values the humanity of her client and is not deflected in that
valuing by any particular client behaviors. The attitude manifests itself
in the counselor’s consistent acceptance of and enduring warmth towards
her client. (p. 95)
Lietaer (2001) offered a view of unconditionality as the therapist’s “valu-
ing the deepest core of the person, what she potentially is and can become”
(p. 105). The humanistic therapist strives to maintain such sentiments
regardless of how badly a client may behave toward others, something that
may indeed prove challenging. As daunting as this may seem, especially
when clients express negative feelings toward their therapist, most are
able to hold their clients in regard by valuing the whole person, warts and

all. Mearns and Thorne (2007) addressed this challenge for the therapist
as follows:
The client feels that the counsellor values him consistently throughout
their relationship, despite the fact that he may not value himself and
even if the counselor does not approve of all the client’s behavior. It is
possible to accept the client as a person of worth while still not liking
some of the things he does. (p. 96)
Therapists’ positive regard for their clients has a number of constructive
effects on the therapeutic relationship and client growth. One thing almost
all clients hope for is someone with whom they feel comfortable, someone
they like, and someone who they feel accepts them as they are. Because so
many clients come to therapy with low self-esteem, self-doubt, shame, and
insecurity, their therapists’ genuine acceptance provides safety and comfort
that enables them to open up and disclose problematic and unattractive
aspects of themselves. Therapists’ acceptance reduces threat, defensiveness,
and clients’ inclination to be self-protective, which, in turn, enables them
to be more open to all of their experiences and be more involved in therapy.
As clients realize that they are seen for who they are and valued, they may
begin to revise their views of themselves in more positive directions and
become more self-accepting. Previously introjected conditions of worth from
significant others (e.g., I am acceptable if . . .) are counteracted and reduced
as clients experience and absorb the therapist’s regard for them, as well as
the regard from others that was previously dismissed because it was felt to
be undeserved and incompatible with the current view of self. Similarly,
clients become less susceptible to the harsh internal judgment of their per-
sonal critic. When clients feel more positively about themselves, they often
gain confidence to try out new behaviors, approach life with greater equanim-
ity, and tolerate life’s challenges and disappointments more effectively.
Although the nonjudgmental empathy of the therapist tends to com-
municate acceptance indirectly, therapist affirmation is a more active and
overtly positive form of valuing the client. Therapist acceptance, regard, and
affirmation are sentiments that often need to be expressed tangibly to the
client to have optimal therapeutic effect.
Research
Orlinsky and Howard (1986) reviewed 94 studies on the relationship

between therapist affirmation and outcome, with 53% demonstrating a posi-
tive relationship. In 1994, Orlinsky et al. presented findings on therapist
affirmation, which included aspects of therapist acceptance, nonpossessive
warmth, and positive regard. Summarizing the results of 154 findings drawn
496 david j. cain

from a total of 76 studies, they found that 56% of the findings were positive.
When viewed from the client’s perspective, the relationship between thera-
pist affirmation and good outcome was 65%.
In a recent review of the research on positive regard by Farber and Doolin
(2011), a meta-analysis of 18 studies produced an aggregate effect size of .27,
suggesting that positive regard had a moderate relationship to good outcome.
Clinical observation and everyday experience suggest that most people
or clients find another’s regard or affirmation to be supportive and therapeu-
tic. Conversely, therapist responses that impair therapy include boredom; rote
and impersonal responses; lack of compassion, understanding, and respect;
coldness or arrogance; and irritation or anger—all of them in clear contrast
to acceptance and regard (Feifel & Eells, 1963; Glass & Arnkoff, 2000).
MUTUAL AFFIRMATION AND LIKING
Premise 5: The therapist and client are mutually accepting and affirming.
When clients come to see a new therapist, one of the main things they
hope for is that they will like and feel comfortable with that person. When
therapists and clients like each other, therapy is apt to proceed more naturally
and effectively. Conversely, clients do not work well with therapists they do
not like—nor do therapists work well with clients they do not like—because
the quality of the relationship is apt to be compromised or strained. As com-
mon sense, clinical wisdom, and research have indicated, client liking of
the therapist is a good predictor of outcome. Of course, therapy is likely to
proceed optimally if such feelings are mutual.
This premise expands Rogers’s (1961) belief about the constructive
effects of therapist unconditional positive regard by suggesting that mutual
liking, acceptance, and affirmation are more powerful than just the therapist’s
acceptance of the client.
When the client likes the therapist, and especially when this liking is
mutual, the client is more able to weather difficult moments in therapy and
strains in the relationship with the therapist. The mutual liking and affirma-
tion seem to create a bond that strengthens the therapeutic alliance, which is
also a good predictor of client progress. Because liking begets liking, allowing
oneself to genuinely like and prize one’s clients is almost inevitably therapeutic.
Research
Client affirmation, defined as respect and liking for the therapist, was
positively related to outcome in about 69% of 154 studies, and therapist

affirmation of the client (acceptance, warmth, or positive regard) was associ-
ated with positive outcome in 56% (Orlinsky et al., 1994). Reciprocal affir-
mation between therapist and client was significantly and positively related
to outcome in 78% of 32 studies (Orlinsky et al., 1994). It would appear that
when clients and therapists are mutually affirming, clients are mostly likely
to achieve constructive change. Indeed, Stoler (1963) found that successful
clients received significantly higher likability ratings from their therapists
than did less successful clients.
BEING CONGRUENT, GENUINE, AND AUTHENTIC
Premise 6: The therapist engages relevant aspects of his or her self in a

congruent manner intended to be in the best interests of the client while
avoiding responses that are irrelevant to the client’s concerns or have the
potential to be harmful.
Being genuine or congruent means that therapists are what they seem to
be. What therapists experience internally is matched by their words, behav-
ior, thoughts, feelings, body language, and manner of expression. Therapist
genuineness lends credibility to everything the therapist does. Congruent
therapists are more likely to be perceived as trustworthy and honest and as
people of integrity. When therapists are transparent, or willing to be known,
their clients are likely to feel trusting. Conversely, clients’ relationships with
their therapists are compromised when therapists are deceptive, dishonest,
misleading, or withholding, any of which may cause the client to be cautious
or guarded.
Congruent therapists do not play the role of therapist or hide behind
it but are naturally themselves in relationship to their clients. Humanistic
therapists eschew any form of deception, phoniness, or manipulative behav-
ior, no matter how benign in intent. They have little or no need to hold back
anything that is relevant to their clients. Valuing transparency, the humanis-
tic therapist may invite the client to inquire about the therapist’s comments,
behavior, thoughts, or feelings about the client. Such openness is often vital
to clients who tend to distrust others or misread others’ intentions.
Rogers came to believe that therapist congruence was the most impor-
tant element in therapy:
It is when the therapist is natural and spontaneous that he seems to be
most effective. . . . Our experience has deeply reinforced and extended
my view that the person who is able openly to be himself in that moment,
as he is at the deepest levels he is able to be, is the effective therapist.
Perhaps nothing else is of any importance. (Rogers & Stevens, 1967,
pp. 188–189)
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Rogers’s view was that authentic encounter with the client was itself therapeu-
tic, a view shared by most humanistic–existential therapists (e.g., Friedman,
1985). Friedman (1985) and other existential therapists have described this
phenomenon as “healing through meeting.” Therapist empathy, positive
regard, and congruence seem to work synergistically and may be viewed as
parts of a larger whole. For clients to feel accepted or prized, they must first
feel that they are being seen accurately and understood by a therapist who is
perceived as congruent and trustworthy. Then the client experiences some-
thing such as, “You see me clearly and still value me, and I trust this valuing
because you are authentic.”
Clients can learn to be more congruent through authentic engagement
with the therapist because realness on the latter’s part often begets realness
in the client. When there is a genuine meeting between therapist and client,
both are enriched by the quality of contact. Clients then have the experience
that they can engage meaningfully with the therapist and, by extension, with
other people.
Therapist self-disclosure that is relevant to a client’s experience (e.g.,
the pain of losing a pet) often helps clients feel understood and less alone
in their troubling feelings. When therapists are transparently real, clients
see that they are people just like themselves, fellow travelers rather than
models of mental health. This often provides perspective for clients and
enables them to become more self-accepting. Therapists can serve as mod-
els for clients of an authentic manner of being. Through vicarious learning,
clients see and experience what it means to be authentic and try out for
themselves more transparent ways of engaging with others. Consequently,
the quality of their primary and everyday relationships is often more intimate
and enriched. They learn that it can be gratifying to be open with others who,
in turn, are more likely to be open with them.
Congruence enables therapists to use themselves in a variety of ways
on behalf of their clients. There are moments in therapy when it is desirable
for therapists to respond spontaneously as the people they are. By doing so,
they often bring forth aspects of themselves that are intended to serve their
clients. In any given course of therapy, the particular relational qualities that
may be growth enhancing will inevitably vary. Just as the client can be under-
stood in terms of a variety of selves that may emerge at different moments
in varying contexts, so too can the therapist. For example, therapists may
engage their sense of humor with their clients, make affirmative comments,
or even challenge them, as long as such behaviors are intended to foster the
therapeutic relationship, experiential learning, or their clients’ well-being.
Being congruent and self-disclosing does not mean that humanistic
therapists should grant themselves license to say or do whatever they feel
simply because it is an honest response. It is essential that the therapist’s

genuineness be relevant to the client and the current therapeutic situation
and be of constructive intent. Congruent expressions of the therapist can, at
times, be a problematic, and sometimes risky endeavor that may be alienat-
ing, harmful, or damaging to the therapeutic relationship. Because congruent
expressions of the self may be for better or worse, such expressions need to
be made judiciously. Therefore, the discriminating expression of self is cer-
tainly called for in the therapeutic endeavor. When they are uncertain about
whether to disclose something potentially risky, therapists may want to ask
themselves, “Is this likely to be relevant and in the best interests of my client
at this time?”
Research
The research on the impact of therapist congruence has been ambigu-

ous and inconsistent. Of 77 results reviewed by Klein, Kolden, Michels, and
Chisholm-Stockard (2002), only 34% showed a positive correlation with
favorable outcomes, with 66% showing no correlation. However, it is worth
noting that they found no negative relationships between therapist congru-
ence and outcome. When clients rated their therapists, results were some-
what more positive (Klein et al., 2002). Klein et al. concluded that “there is
both empirical and theoretical justification for congruence as a central com-
ponent of a complex conception of the therapy process” (p. 396). Studies that
have asked clients to identify the most important aspects of their therapy in
relationship to outcome have found that therapist openness, realness, or genu-
ineness are rarely cited (Burckell & Goldfried, 2006; Feifel & Eells, 1963).
However, it is interesting to note that therapist trustworthiness does emerge
as an important characteristic identified by clients in good outcomes (Burckell
& Goldfried, 2006; Conte, Ratto, Clutz, & Karasu, 1995). This sense of
trustworthiness is likely influenced by the therapist being experienced as
authentic.
In a more recent review of the congruence literature, Kolden, Klein,
Wang, and Austin (2011) conducted a meta-analysis of 16 studies, represent-
ing 863 clients, on therapist congruence, finding a modest effect size of .24.
They concluded that congruence is a “noteworthy facet of the therapeutic
relationship” (p. 68).
It is difficult to make sense of these inconsistent findings. Kirschenbaum
(1979) believed, as I do, that congruence was the least clearly defined and
understood of Rogers’s core conditions. Therefore, congruence needs a clearer
definition since it remains “the most difficult of the core conditions for thera-
pists to get right” (Kirschenbaum & Jourdan, 2005, p. 43).
One way that transparency is communicated is through therapist
self-disclosure. Barrett and Berman (2001) found that increased therapist
500 david j. cain

self-disclosure was related to reductions in clients’ symptom distress and
increases in liking for their therapists. Barrett and Berman also cited previ-
ous research showing that therapist self-disclosure was associated with cli-
ents seeing the therapist as warm, friendly, open, and helpful. Hill and Knox
(2001) reviewed the modest literature on therapist self-disclosure, noting
that reassuring and reciprocal disclosure “might help to build the therapeu-
tic alliance, which in turn might allow clients to benefit further from other
interventions and feel confident to explore themselves more thoroughly and
make changes” (p. 416). Thus, some modest evidence exists that the quality
of the relationship is improved and problem distress is reduced.
RELATIONAL DEPTH
Premise 7: The therapist and client engage in a manner that enhances

the depth and quality of their working relationship.
David Mearns and Mick Cooper, coauthors of Working at Relational Depth
in Counseling and Psychotherapy (2005), made a powerful case that the depth
and quality of contact between therapist and client enhance the impact of
the working therapeutic relationship. They defined relational depth as a “state
of profound contact and engagement between two people, in which each per-
son is fully real with the Other, and able to understand and value the Other’s
experiences at a high level” (Mearns & Cooper, 2005, p. xii). Relational depth
refers to moments of intense and intimate encounter, as well as an enduring
quality of contact and connection, between two people. Therapists working
at relational depth have a high level of presence and are immersed in, acces-
sible to, and responsive to their clients. They are sensitively attuned to and
resonate intuitively with all aspects of their client’s communication, behav-
ior, and being. They are receptive to being affected and influenced by their
clients because they experience a sense of “we-ness” 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
mutuality of engagement and spontaneous expression by therapist and client.
Cooper (2013) refined the definition of relational depth as follows: “rela-
tional depth is about openness and fluidity—a willingness to move beyond
fixed, sedimented assumptions . . . [and] is about moving away from all-or-
nothing thinking, to an appreciation of the intricacies and complexities of
any person or phenomenon” (p. 62). To this, Cooper added that it is
a sense of connectedness and flow with another person that is so power-
ful that it can feel quite magical. At these times, the person feels alive,
immersed in the encounter, and truly themselves; while experiencing the
other as open, genuine and valuing of who they are. (p. 69)

Julius Seeman (2002) described a similar therapeutic relationship as one
characterized by a high level of connection and communication between
therapist and client.
Research
There is modest but accumulating evidence that relational depth is

related to good outcome. Wiggins (2013, as cited in Cooper, 2013), using
a Relational Depth Inventory, found that relational depth accounted for
as much as 10% to 30% of overall client outcomes. Leung (2008, as cited
in Cooper, 2013), exploring whether moments of relational depth had an
enduring impact, found that both therapists’ ratings (5.69) and clients’
ratings (5.78) on a scale ranging from 1 to 7 suggested that such moments
were important for therapeutic change. Research by Cooper (2013) identi-
fied two impacts of relational depth: (a) an experience of such moments
as facilitative, healing, and changing and (b) a view of them as conducive
to the therapeutic process itself. Clients described the long-term effects
of these moments as increasing a sense of connection to self, enabling
them to feel better and more powerful and enhancing their relationships
with others.
FORMING A THERAPEUTIC ALLIANCE
Premise 8: The therapist and client form a therapeutic alliance that

enhances the quality of their working relationship.
The Therapeutic Alliance
The ability to form a meaningful, collaborative working relationship

between client and therapist can be understood as constituting the founda-
tion for effective therapy. The therapeutic alliance has been defined in various
ways. Gaston (1990) suggested that some of the following components of the
alliance can be measured by a number of current scales:
77 the client’s affective relationship to the therapist,
77 the client’s capacity to purposefully work in therapy,
77 the therapist’s empathic understanding and involvement, and
77 client–therapist agreement on the goals and tasks of therapy.
When therapist and client work collaboratively to cocreate an optimally
individualized therapy, good outcomes are likely.
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Research
A summary by Horvath, Del Re, Flückiger, and Symonds (2011) of

200 research reports covering more than 14,000 treatments, regarding the
relationship between the therapeutic alliance and outcome, showed an
aggregate effect size of .275 (p < .0001). Alliance research showed that
client perception of the therapist’s contribution to the therapeutic bond
or alliance was related to positive outcome in 67% of studies and was
never negatively associated with outcome when viewed from the client’s per-
spective (Sachse & Elliott, 2002). S. A. Baldwin and Imel (2013) reported
that “meta-analyses of the alliance-outcome correlation suggest a consistent
relationship between strong alliances and good therapy outcomes” (p. 282).
In the National Institute of Mental Health Treatment of Depression
Collaborative Research Program, Krupnick et al. (1996) reported results
indicating that the therapeutic alliance had a significant impact on out-
come for both cognitive–behavioral and interpersonal psychotherapies,
as well as for active and placebo pharmacotherapy. When Castonguay,
Goldfried, Wiser, Raue, and Hayes (1996) investigated the therapeutic
alliance in cognitive therapy, their results revealed that the two common
variables, therapeutic alliance and the client’s emotional experiencing,
were related to improvement.
Client Contribution to the Therapeutic Alliance
In recent years, it has become clear that clients contribute in meaning-

ful ways to the quality of the therapeutic relationship. This, of course, makes
good sense when one considers that clients and therapists are part of the same
field and, therefore, have reciprocal effects on each other.
Research
Greaves (2006) found that clients contributed to fostering heal-

ing responses from their therapists by being present and engaging in an
authentic manner with them. Such client behavior seemed to elicit similar
responses from therapists. Clients were also active in building rapport with
their therapists by expressing prosocial behaviors such as voicing apprecia-
tion for them. Client expressions of vulnerable experiences fostered empathic
responses from their therapists, and client expressions of optimism and hope
resulted in reciprocal hope from their therapists. Consistent with these find-
ings, Fitzpatrick, Janzen, Chamodraka, and Park (2006) found that client
expressions of vulnerability resulted in therapist openness and probably in an
increase in the quality of the bond. Furthermore, because clients attributed

positive meanings to their therapists’ responses, they expressed more positive
emotions and engaged in more exploration.
Orlinsky et al. (1994) summarized 55 findings related to the client’s
contribution to the therapeutic alliance, finding a significant relationship
in 67% of the cases. The client’s positive contribution to the therapeutic
alliance was associated with good outcome for cases lasting 20 to 40 sessions.
A study by Krupnick et al., carried out in 1996 and reported by Bohart and
Wade (2013), examined the relative contributions of client and therapist
to the alliance. It showed that clients’ contributions had more impact than
those of therapists on client outcome. These studies and others consistently
bring us back to two major conclusions: (a) Clients’ behaviors and attitudes,
more than those of therapists, contribute to their progress and (b) therapists
do not simply “do for” the client; rather, the quality of the therapist’s response
to the client is affected by how the therapist experiences the client.
BEING COLLABORATIVE AND COOPERATIVE
Premise 9: The therapist and the client work in a collaborative and coop-
erative manner.
The therapeutic alliance is strengthened by mutual collaboration and
cooperativeness between therapist and client. When clients and therapists
become partners and collaborate to assess the course of therapy and its effec-
tiveness, the client is likely to benefit by achieving better outcomes. This col-
laboration not only appears to involve the therapist’s ability to communicate
acceptance, warmth, and empathy but also requires the client and therapist to
come to a mutual agreement on the goals of treatment and how those goals will
be reached (Hatcher & Barends, 1996). One of the major changes in enhancing
the quality of psychotherapy and good outcome has come from therapists and
clients engaging in formal and informal assessment designed to review the cli-
ent’s progress periodically (e.g., Duncan, 2010; Lambert & Shimokawa, 2011).
Research
Orlinsky et al. (1994) reported on 46 process–outcome findings on

therapist–client collaboration versus the therapist proceeding in a directive
or permissive fashion. Overall, 43% of the findings indicated a significant
association with a collaborative therapeutic style and outcome. This figure
rose to 64% when viewed solely from the client’s perspective. In terms of
client collaboration versus dependent or controlling style, 64% of 42 find-
ings showed good outcome to be positively associated with therapist–client
collaboration, and none favored either a dependent or controlling style of
504 david j. cain

relating. Collaboration also involves clients participating more fully in
co-creating the style and course of their therapy. Orlinsky, Rønnestad, and
Willutzki (2004) reviewed the research on therapist collaboration and con-
cluded that “favorable outcomes were more likely with therapist collabora-
tiveness as viewed from the patient’s perspective” (p. 350).
A meta-analysis of 19 studies, with a sample of 2,260 clients, centering
on therapist–client collaboration, showed that the average effect size was .27,
suggesting a medium relationship with outcome (Tryon & Winograd, 2011).
This same review considered 15 studies involving 1,302 clients to examine
the relationship between goal consensus and outcome, with goal consensus
defined as agreement between therapist and client on the goals of therapy and
the processes to be used to reach them. The effect size was .34 (p < .0001).
Relatively recent research by Lambert and Shimokawa (2011) made
a strong case for more formalized approaches to collecting client feedback
to assist the 5% to 14% of clients who actually worsen in therapy. As has
been previously mentioned in this chapter, and confirmed by Lambert and
Shimokawa, therapists are often unaware that their clients are deteriorating
because therapists tend to be poor judges of their own therapy. Lambert and
Shimokawa, using the Partners for Change Outcome Management System,
regularly obtained written feedback from the therapists’ clients regarding the
ongoing therapy and quality of the therapist–client relationship and con-
cluded that the number of clients who deteriorate could be cut in half by use
of the feedback.
CLIENT INVOLVEMENT
Premise 10: The client is actively involved in and receptive to the thera-
peutic endeavor, participates cooperatively, has a positive expectation
that therapy will be helpful, and takes responsibility for change.
In recent decades, it has become clear that it is primarily the client
who makes therapy work. As veteran researchers Bergin and Garfield (1994)
concluded after reviewing decades of psychotherapy research,
It is the client more than the therapist who implements the change pro-
cess. If the client does not absorb, utilize and follow through on the facili-
tative efforts of the therapist, then nothing happens. Rather than argue
over whether or not “therapy works,” we could address ourselves to the
question of whether or not “the client works”! . . . Clients are not inert
objects upon whom techniques are administered. . . . People are agentic
beings who are effective forces in the complex of causal events. . . . As
therapists have depended more upon the client’s resources, more change
seems to occur. (p. 826)

Client Role Involvement
Client role involvement denotes the extent to which a client actively

fulfills the client role, engages cooperatively, and shows commitment to the
therapy process. It also suggests that clients take responsibility for themselves,
attend sessions as scheduled, have a focus and goals, come prepared to engage
their issues, and are receptive to learning and change.
Clients’ level of active involvement and participation is likely to increase
as they experience their therapists’ presence, empathy, regard, relational depth,
and authenticity. The quality of the relationship early on is critical to the devel-
opment of a sound working relationship and getting therapy off to a good start.
Research
Research on client role engagement or personal involvement is a strong

predictor of good outcome. In a series of 54 outcome studies, 65% showed a
positive relationship with good outcome (Sachse & Elliott, 2002). Orlinsky
et al. (1994) found that 92% of findings show a significant positive relation-
ship to outcome from the therapist’s perspective. Highly active participation by
the client is consistently correlated positively with outcome (Gomes-Schwartz,
1978; Kolb, Beutler, Davis, Crago, & Shanfield, 1985; O’Malley, Suh, & Strupp,
1983). Bohart and colleagues (Bohart & Tallman, 2010; Bohart & Wade, 2013)
have reviewed the evidence and concluded that client involvement in therapy
is the most important factor in making therapy effective. What therapists can
do is support, stimulate, and encourage clients’ investment in their own therapy.
Regarding mandated therapy, a meta-analysis by Parhar, Wormith,
Derkzen, and Beauregard (2008) of 129 studies of offenders referred for cor-
rectional treatment in the criminal justice system showed that mandated
clients did not do well in therapy, whereas clients who came voluntarily had
good outcomes.
CLIENT POSITIVE EXPECTATIONS AND THERAPIST OPTIMISM
Premise 11: The therapist views clients as people capable of construc-

tive change and strives to support their resourcefulness, freedom, and
autonomy in determining the direction of therapy and how their goals
will be achieved.
Implicit in Carl Rogers’s therapeutic work was a strong belief in the
client’s capacity for growth. Rogers’s (1959) core belief in an actualizing ten-
dency clearly represented his view that there was an “inherent tendency of
the organism to develop all its capacities in ways which serve to maintain
506 david j. cain

or enhance the organism” (p. 2). Rogers believed that clients’ actualizing
tendency would be optimized when they experienced an interpersonal envi-
ronment characterized by adequate levels of empathy, acceptance, and con-
gruence in their therapists. Similarly, Bohart and Tallman (1999) made a
compelling argument that therapy was a learning process and that engaging
the client’s self-healing potential was essential in helping them. Furthermore,
evidence presented by Bohart and Tallman suggested that most people and
clients manage their lives adequately without the assistance of professional
help by drawing on their own and other resources (e.g., self-help books, sup-
portive friends and family, and other available resources).
Clients tend to initiate therapy with a positive expectation that it will
be helpful, often making their greatest gains in the first handful of sessions.
Miller et al. (1997) made a strong case that “merely expecting therapy
to help goes a long way toward counteracting demoralization, mobilizing
hope, and advancing improvement” (p. 30). They also contended that
“the creation of hope is strongly influenced by the therapist’s attitude
toward the client during the opening moments of therapy” (pp. 30–31).
Clearly, the combination of therapists’ and clients’ positive expectations
for change constructively affects the quality of their engagement and client
progress.
In a similar vein, humanistic therapists place a high value on encour-
aging and supporting clients’ freedom and autonomy in decision making
about what they want to change and how such change might be achieved.
This value emerges naturally from the humanistic therapist’s belief that cli-
ents have the right to choose what they want and how to conduct their
lives without undue influence, guidance, advice, or specific suggestions for
change.
Research
Lambert’s (1992) research indicated that about 40% of outcome in ther-

apy was related to client resources, and another 15% of outcome was accounted
for by clients’ positive expectations and hope that therapy would be helpful.
Such hopefulness is strongly influenced by the therapist’s optimism and
conviction that clients can mobilize or develop their resources for change.
As therapists embrace this view, they depend more on their clients to deal
with their problems. This clearly shifts therapists’ responsibility from effect-
ing change to that of facilitating clients’ capacity to mobilize their current
resources and potential for change.
Additional research cited by Miller et al. (1997) suggested that “hope
and expectancy give people a measurable advantage in many areas of life”
and that “fostering a positive expectation for change may actually be a

prerequisite for successful treatment” (p. 31). Bohart and Wade (2013) cited
studies indicating that there was a small but significant effect size supporting
the relationship between clients’ positive expectation and therapy success.
They also cited research suggesting that good outcome was more likely when
clients’ expectations were moderate, as opposed to very high or very low.
They cited a meta-analysis of 46 samples by Constantino, Glass, Arnkoff,
Ametrano, and Smith (2011, as cited in Bohart & Wade, 2013) that reported
a small but significant effect size regarding the association between client
positive expectations for change and good outcome.
Client Openness Versus Defensiveness
Premise 12: The client participates in therapy with openness and recep-
tivity and in a nondefensive manner.
Client openness and nondefensiveness are among the very best predic-
tors of good outcome. Client openness represents a willingness to talk about
problems and to disclose and process unpleasant aspects of self and experience.
Conversely, client defensiveness impairs the therapeutic process because the
client avoids dealing with difficult issues, experiences, or disagreeable aspects
of the self. Clients who are open and participate cooperatively in their therapy
are more likely to be motivated to change and are receptive to multiple aspects
of the therapeutic process, including the willingness to look at themselves,
despite the possibility that doing so may be threatening to the self as currently
conceived.
Therapists, of course, contribute to clients’ openness by providing a safe,
trustworthy, and understanding environment in which clients feel accepted
as they are, including their flaws and limitations.
Research
A variable clearly related to involvement is the client’s level of recep-

tivity to multiple aspects of the therapeutic process. Research has indicated
that client openness, as opposed to defensiveness, is related to good outcome
in 80% of studies (Orlinsky et al., 1994). Clients’ cooperative participation
in therapy showed a signification association with positive outcome in 69%
of 50 studies (Orlinsky et al., 1994), and client motivation or desire for ther-
apeutic involvement showed a significant relationship with outcome in 50%
of 28 studies (Orlinsky et al., 1994). In 87% of studies reviewed by Orlinsky
et al. (1994), clients’ behavioral and cognitive processing manifested while
talking were associated with effective use of therapy. The evidence seems
508 david j. cain

clear: When clients are active, open, and involved participants, they are
likely to make progress. Bohart and Wade (2013) reported studies indicating
that as the bond between therapist and client increased, so too did clients
expressive openness and that reduction of self-concealment was found to be
a good predictor of reduction in clients’ distress.
CLIENT EXPRESSIVENESS AND EMOTIONAL EXPERIENCING
Premise 13a: Clients attend to, express, and process their feelings and emo-
tion schemes with adequate depth to achieve clarity of personal meaning.
Client Expressiveness
Closely related to openness are clients’ capacity and willingness to

express themselves. In general, clients who are in touch with their feelings,
enabling them to express their thoughts and feelings in therapy, have a posi-
tive prognosis. In contrast, those who do not disclose or process their feelings,
or who describe them in a lifeless or detached manner, are less likely to have
favorable outcomes. Some clients express and process their feelings naturally,
and others need assistance and guidance in doing so. Fortunately, sensitive
and effective therapists can increase clients’ expressiveness by articulating
their experiences in a vivid and evocative manner.
Research
In a review of studies of client expressiveness, Orlinsky et al. (1994)

reported that, out of 51 findings, 63% showed a positive relationship with
outcome. Moreover, Beutler, Crago, and Arizmendi (1986) showed that
clients who were open, in touch with their feelings, and able to express their
thoughts and feelings in therapy had a positive prognosis. Butler, Rice, and
Wagstaff (1962) and Rice and Wagstaff (1967) found that psychotherapy
outcomes could be predicted as early as the second session in relation to
client expressiveness. Expressive clients had more positive outcomes, and
nonexpressive clients (characterized as having dull, lifeless ways of describ-
ing self and inner experience) had less favorable outcomes. Noting that less
expressive clients might have poorer outcomes, Wexler and Butler (1976)
demonstrated that client expressiveness could be improved by therapists’
responses, although their study was limited in that it included only a single
case study of success.

CLIENT EXPERIENCING AND PROCESSING EMOTION
Premise 13b: The therapist focuses on and encourages the client to attend
to and process potent emotional experiences, with the intent to facilitate
adaptive client learning and more effective functioning.
A client’s willingness to self-explore and process emotion seems essential
to successful therapy. However, not every client who wants to explore will
necessarily be good at it. Clients’ capacity to access and process their feelings
varies from being almost entirely out of touch with their feelings to being
hypersensitive to them. As noted earlier, clients’ capacity for emotional expe-
riencing is an important element in determining whether or not they are likely
to benefit from therapy. Fortunately, as Gendlin (1996) has noted, clients can
learn to focus and experience their felt sense (the way the body experiences
reality) of problems and situations, and doing so often leads to fresh ways of
looking at self and others. Gendlin (1984) described the felt sense as “the
client inside us, a kind of self-response process” (p. 83). New ways of being and
behaving naturally emerge from seeing with fresh eyes and hearing with fresh
ears. Meaningful and substantive change is visceral, in one’s bones, as opposed
to being primarily cognitive. The fact that experiencing can be learned takes
on greater significance when one understands that clients do not, without
assistance, tend to deepen their experiencing. One way to conceive of client
experiencing is that it represents internal receptiveness and openness, because
it is a manner of listening and relating to oneself that is therapeutic. Clearly,
therapists’ ability to enable their clients to experience more fully is essential
to their intrapersonal and interpersonal learning.
Focusing-Oriented Research
The capacity to experience a felt sense has emerged as an important

variable in determining whether the client is likely to benefit from therapy
(Greenberg & Pinsof, 1996). A substantial and growing body of research
has demonstrated that effective processing of bodily felt experiences leads to
good outcome.
Gendlin’s (1996) studies on client-centered therapy found that clients
high in the ability to work with inner experience appeared to benefit more
from psychotherapy. Klein, Mathieu-Coughlan, and Kiesler (1996), using the
Experiencing Scale, also found support for the association between high lev-
els of client experiencing and therapeutic change.
Hendricks (2002) reported on 28 studies showing that (a) higher
experiencing levels correlate with a more successful outcome in therapy in
a variety of therapeutic orientations and client problem types; (b) clients
can be taught the ability to focus and increase their experiencing level; and
510 david j. cain

(c) therapists who themselves focus seem to be more effective in enabling
their clients to focus.
The client’s personal construction of the meaning of events in therapy
has shown that experiencing is positively related to outcome in 51% of
39 studies (Orlinsky et al., 1994). Iberg (1996) found that clients reported
greater impact in sessions when therapists used focusing-oriented questions.
Leijssen (1996), who conducted a study to determine whether focusing
enhanced client-centered therapy, found that 75% of positive sessions used
focusing steps, in contrast to only 33% of negative sessions. Client focusing,
whether a part of focusing-oriented psychotherapy or another therapeutic
approach, seems to enhance the quality of individual sessions and good out-
come. (See also Chapter 8, this volume.)
Emotion-Focused Research
Attention to client emotion is characteristic of all humanistic thera-

pies, but it is the primary focus of emotion-focused therapy (EFT). In the
past 20 years, EFT has been extensively researched, led by Les Greenberg and
Robert Elliott, the founders of this approach, along with their colleagues.
Research on depth of experiencing in therapy has consistently been
shown to relate to good outcome. The literature on client processing of
emotion reviewed by Greenberg, Korman, and Paivio (2002) concluded
that (a) processing information in an experiential manner is associated with
productive client involvement and predicts successful outcome; (b) therapies
focusing on clients’ emotional experience, when successful, are associated with
changes in clients’ in-session emotional experiences; (c) emotion is important
in reorganizing personal meaning; and (d) research on therapist processing of
clients’ emotion indicates that their ability to differentiate their emotional
experience accurately is integral to healthy functioning.
In a review of process–experiential therapy or EFT, Elliott and Greenberg
(2002) reported that (a) 11 studies yielded large pre- to posttherapy effect
sizes with a mean of 1.34; (b) two controlled studies showed a large advantage
for EFT clients versus wait-listed control groups; and (c) in five comparative
outcome studies, EFT was superior to group psychoeducational treatments,
cognitive–behavioral therapy, a cognitive restructuring treatment, behav-
ioral problem solving, and client-centered therapy for a variety of problems.
A randomized clinical trial that compared the effectiveness of EFT with
that of client-centered therapy showed that both client-centered therapy and
EFT were effective treatments for alleviating depression, although EFT was
more effective in attenuating interpersonal problems and increasing self-
esteem (Greenberg & Watson, 1998). In a replication study, results suggested
that, with a second sample of 38 clients (19 in each group), EFT was more

effective in alleviating depressive symptoms and equally as effective in allevi-
ating interpersonal problems and increasing self-esteem. When the two sam-
ples were combined, providing sufficient power to find differences, EFT was
found to be more effective on all indices of change (Goldman, Greenberg,
& Angus, 2006).
Goldman, Greenberg, and Pos (2005) looked at the relationship between
theme-related depth of experiencing and outcome in experiential therapy
with depressed clients. Analyses revealed that the client level of experienc-
ing on core themes in the last half of therapy was a significant predictor of
reduced symptom distress and increased self-esteem. Studies that examined
expressed arousal showed that a combination of visible emotional arousal and
experiencing was a better predictor of outcome than either index alone, sup-
porting the hypothesis that it is not only arousal of emotion but also reflection
on aroused emotion that produces change (Missirlian, Toukmanian, Warwar,
& Greenberg, 2005). A more recent study showed that better-outcome
clients expressed significantly more productive, highly aroused emotions than
poorer-outcome clients, suggesting that expression of highly aroused emo-
tions is important in facilitating change (Greenberg, Auszra, & Herrmann,
2007). Elliott et al. (2013) reported studies that showed that processes that
involve “depth of experiential self-expression have a central place among the
therapeutic ingredients mentioned by clients as helpful and that these pro-
cesses discriminate between ‘very good’ and ‘rather poor’ sessions” (p. 521).
In an extensive review of the literature, Elliott, Greenberg, and Lietaer
(2004) concluded that “experiential treatments have been found to be effec-
tive with depression, anxiety, and trauma, as well as to have possible physical
health benefits and applicability to clients with severe problems, including
schizophrenia” (p. 510). Recent process research (Elliott et al., 2004) has
consistently demonstrated a relationship between in-session emotional acti-
vation and outcome in various therapies.
Research on depth of experiencing in therapy has regularly been shown
to relate to outcome, especially in client-centered therapy (Greenberg et al.,
2002). Warwar and Greenberg’s (1999) research indicated that good-out-
come clients being treated for depression showed both higher emotional
arousal and greater depth of experiencing in emotion episodes. Sachse’s
(1992) research showed that therapists’ responses may deepen, maintain, or
flatten client experiential processing and self-exploration. Indeed, client self-
exploration and outcome were reported to be significantly associated in 30%
of 79 findings by Orlinsky et al. (1994).
Mahrer, Nadler, Dessaulles, Gervaize, and Sterner (1987) showed that
good moments in therapy are characterized by emotional expression. Other
studies have found similar results showing a relation between emotional
experiencing and outcome in therapy (Beutler, 1999; Foa & Jaycox, 1998;
512 david j. cain

Greenberg & Foster, 1996; Hirscheimer, 1996; Malcom, 1999; Orlinsky et al.,
1994; Paivio & Greenberg, 1995). In sum, the evidence that working effec-
tively with client emotion leads to good outcome is strong and growing. One
should note, however, that emotional arousal alone is not sufficient, and good
outcomes are distinguished from poor ones by clients’ making sense of their
emotions. Emotional experiences need to be aroused, processed, and reflected
on cognitively for optimal benefit.
Emotion-Focused Therapy for Couples

In a meta-analysis on EFT for couples, Johnson, Hunsley, Greenberg,
and Schindler (1999) found a large effect size of 1.3. Approximately 90% of
treated couples rated themselves better than did controls, and 70% to 73% of
couples recovered from marital distress at follow-up. The Society for Clinical
Psychology of the American Psychological Association has identified emo-
tionally focused couples therapy as an empirically supported treatment for
marital distress (Johnson et al., 1999).
In sum, there is a large and growing body of research demonstrating the
effectiveness of EFT for a variety of problems (see Chapter 10, this volume).
As Elliott et al. (2013) noted, “For relational and interpersonal problems, EFT
clearly meets criteria as an efficacious and specific treatment” (p. 523, italics
added).
CLIENT LOCUS OF CONTROL AND EVALUATION
Premise 14: Clients develop and operate from an internal locus of control
and evaluation.
Locus of control (internal vs. external) refers to the extent to which peo-
ple believe that they can control events. In general, “internals” believe that
the outcomes of their actions result from their own abilities, and “externals”
attribute outcomes of events to external circumstances. Similarly, Bandura’s
(1997) concept of self-efficacy reflects people’s beliefs that they can succeed
in a particular activity. Locus of evaluation indicates whether people depend
on themselves (internal) or others (external) to make judgments regarding
their beliefs and behavioral choices.
From a humanistic perspective, developing and operating from an inter-
nal locus of control and evaluation is considered central to psychological
health; it is enhanced to the degree to which clients see themselves as cap-
tains of their ships and take responsibility for themselves and their actions.
As Rogers (1961) often stated, his goal was to free his clients to determine
the direction of their therapy and their lives and to empower them to make

choices compatible with their personality, beliefs, and values. When thera-
pists trust their clients’ resourcefulness to right themselves, they keep clients
in charge of their lives and enable clients to use what they offer them in their
own ways. As clients develop and strengthen their internal locus of control
and evaluation, they are more likely to feel secure and trusting in their judg-
ment and decision making. When clients process emotion and experience a
ring of truth in their discovery, they are more likely to trust themselves and
feel empowered and confident in their choices.
Research
Giacomo and Weissmark (1992) examined the work of 15 therapists

in which each therapist had one successful and one unsuccessful case. The
authors sought to understand the differences, finding that successful clients
became more internal, more selective, and more conditional, and the unsuc-
cessful clients remained external, less selective, and less conditional. Giacomo
and Weissmark also noted that the client’s quality of participation in treat-
ment was significantly related to outcome. In a study of 84 institutionalized
female drug addicts, Kilmann and Howell (1974) found that clients with an
internal locus of control rated themselves more favorably, showed more effort
to be successful, and appeared to be more involved in therapy. They became
more reflective and made more attempts to gain self-understanding. A look
at the overall findings indicated that internals were better therapy candidates
than externals.
A study by Abramowitz, Abramowitz, Roback, and Jackson (1974)
indicated that clients who had an internal locus of control fared better with
nondirective therapy, characteristic of most humanistic therapies because
client agency and choice are emphasized. Foon (1987) studied the rela-
tionship between client locus of control and good outcome, finding evi-
dence that an internal locus of control was related to positive assessments
of therapy and good outcome. An early study by Raskin (1952) concluded
“that locus-of-evaluation scores may be used as a criterion of therapeutic
progress, and that this factor is correlated significantly with such other cri-
teria as self-regarding attitudes, understanding-and-insight and maturity of
behavior” (p. 1).
THE SELF and SELF-CONCEPT
Premise 15: The therapist focuses on the self of the client with the inten-
tion to help the client gain clarity about the self, resolve discrepancies
in the self-concept, and increase self-efficacy.
514 david j. cain

As noted earlier, the self is central to how things are perceived because
what one attends to and how it is interpreted is mediated by the self. As
Purkey and Stanley (2002) noted,
This view of self as a mediating construct in human behavior is con-
sistent with the views of humanistically-oriented psychotherapists who
have long argued that the potent evaluative nature of the self creates a
filter through which all new phenomena are interpreted and subsequent
behavior mediated. (p. 482)
Markus (1977) argued that an individual’s self-system is composed of
self-schemas, defined as “cognitive generalizations about the self, derived
from past experience, that organize and guide the processing of self-related
information contained in the individual’s social experiences” (p. 64).
Bandura (1997) has long contended that people’s sense of their self-
efficacy reflects their beliefs that they have varying degrees of control over
their thoughts, feelings, and behaviors. As self-efficacy increases, people
become increasingly confident about their capacity to manage their lives
effectively.
Humanistic therapies share an emphasis on the importance of focusing
on the self as perceived by the client. A benefit of humanistic psychothera-
pies is that they facilitate self-definition and redefinition by enabling clients
to achieve greater clarity about who they are as opposed to a distorted view
of self. As clients come to see themselves in new ways, they are more likely
to act in a manner consistent with these revised ways.
Research
In a review of research on the self-concept, Purkey and Stanley (2002)

noted that positive and realistic perceptions of the self were requisites for psy-
chological well-being and that poor self-concept was associated with multiple
forms of psychopathology. Rogers and Dymond (1954) and their colleagues at
the University of Chicago conducted a series of studies on the self and psycho-
therapy and found that positive changes in self resulted from therapy, includ-
ing “greater self-understanding, increased inner comfort, greater confidence
and optimism, increased self direction and self-responsibility, more comfort-
able relationships with others, and less need for self-concealment” (p. 18).
Raimy (1948), who pioneered studying the self and psychotherapy, found that
clients who experienced successful outcomes in counseling reported more
self-approval and less self-disapproval than clients who experienced less suc-
cessful outcomes. Rogers (1961) reported research that indicated that clients
who successfully completed therapy tended to perceive the self as more wor-
thy and become more accepting of others. Furthermore, clients became more

self-directing, with their beliefs based on experience rather than external
influences. There was also less discrepancy between self and ideal self.
Rennie’s (2002) qualitative research showed that clients identified ther-
apists’ focus on the client’s self as contributing to their change. Self-focus was
associated with (a) awareness of problems and issues, (b) motivation to change,
(c) pursuit of change, (d) acquisition of new understandings, (e) acquisition of
new behaviors, and (f) changes in the interpersonal environment.
INDIVIDUALIZING PSYCHOTHERAPY
Premise 16: The therapist and client individualize therapy by being col-
laborative partners in the definition of the client’s problems, desired
goals, means to achieve those goals, and the definition and creation of
an optimal therapeutic relationship.
A compelling argument can be made that no one knows the client better
than the client. The belief that clients are the best experts on themselves is
critical for humanistic therapists to work effectively with them. Furthermore,
because each client is unique, clinical wisdom and many prominent therapists
(e.g., Lazarus, 2005) have pointed to the importance of individualizing therapy.
It is the therapist’s responsibility to adapt and accommodate in a manner that
works best for a given client. Therapists’ meta-communication about therapy
is vital in helping them know what fits and works for a specific client. Clients
need and benefit from different things at different times. Therefore, each course
of therapy needs to be cocreated by therapist and client as it evolves to increase
the likelihood of client benefit. Although clients take the lead in deciding what
problems are to be addressed and what their related goals are, therapists and cli-
ents work together in defining and creating an optimal therapeutic relationship
and course of therapy to achieve those goals. In this approach, the therapist is
cautious about defining a priori relational factors that are considered optimal.
If therapists take the role of learners in relationship to their clients, they are
likely to observe and inquire about what is needed or apt to be most fruitful in
specific situations regarding evolving goals and the therapeutic processes and
relational qualities most likely to achieve them.
Research
Research reported earlier indicated that client perceptions of therapist

behavior were better predictors of outcome than those of the therapist or
external judges. Bachelor’s (1988) research showed that what was defined as
empathy varied from client to client; thus, the therapist needed to ensure that
qualities and behaviors beneficial to the client were perceived and experienced.
516 david j. cain

Grote’s (2005) qualitative research on feeling understood showed that mul-
tiple therapist qualities and behaviors other than empathic ones contributed
to this experience. Rennie’s (2002) qualitative research showed that clients
were self-aware agents in therapy and, therefore, responded in their own ways
to the therapist’s responses and proposals. Moreover, clients creatively used
whatever their therapists offered them, selectively and in their own way.
Tompkins, Swift, and Callahan (2013) showed that incorporating clients’
preferences results in fewer dropouts and improved outcomes. These studies
and others like them make a compelling case that therapists need to remain
mindful of what is likely to serve the client best at a given time.
Miller et al. (1997), Lambert and Shimokawa (2011), and Bohart and
Tallman (1999) made a strong case that seeking out feedback, written and
oral, from the client at regular intervals, and especially at times when therapy
seems to have bogged down, improved the effectiveness of therapy.
CLIENT’S EXPERIENCE OF THE THERAPEUTIC RELATIONSHIP
Premise 17: The client experiences in the therapist the relevant rela-
tional qualities, behaviors, and intents that facilitate change and growth
as defined by the client.
Rogers (1961) helped us understand that, for therapy to be effective, the
core conditions needed to be perceived or experienced by the client to be effec-
tive. Both research and clinical experience have suggested that a large number
of therapist qualities, attitudes, and behaviors lead to constructive therapeutic
change in the client. However, because each client and course of therapy are
unique, it is essential that the therapist be aware that what is important for
each client to benefit optimally will vary. Furthermore, what clients benefit from
most will also vary over the course of therapy and even within sessions. What
matters most to a given client (e.g., feeling supported or encouraged) will vary;
thus, when the specific constellation of therapeutic qualities and behaviors
needed by the client to use therapy effectively are offered and perceived,
then therapeutic effectiveness will be increased. Because therapists are poor
judges of their impact on clients, it seems desirable for therapists to initiate
dialogue regarding what the client is experiencing in the therapy, especially
at moments within sessions or in various phases of therapy when the therapist
senses that something may be problematic.
Research
One of the core premises of Rogers’s (1961) theory and research was
that the client needed to experience the core conditions of empathy, positive

regard, and congruence to benefit from them. It was not sufficient for thera-
pists to believe that they communicated such attitudes or conditions unless
they were perceived as such by the client. Research reported earlier indicated
that client perceptions are almost always a better prediction of therapists’
responsiveness than therapists themselves, who tend to overestimate their
effectiveness. Studies by Rennie (2002) indicated that clients’ participation
in therapy was related to their perception of the responsiveness of their thera-
pists. Research by Timulak (2007) suggested that clients reported several types
of experiences as helpful, including awareness, insight, and self-understanding;
behavioral change and problem solving; exploring feelings and emotional
experiencing; empowerment; relief; feeling understood; involvement; and
reassurance, support, safety, and personal contact.
Bohart and Wade (2013) summarized research and reported on a num-
ber of client preferences for facilitative relational qualities and behaviors
in their therapist. These preferences include genuineness or realness, pres-
ence, reduction of stigma, enhancement of the client’s sense of self-efficacy,
openness, respect, trustworthiness, adapting to client needs, being accept-
ing, being patient, providing emotional support, and offering neutrality and
sensitivity to cultural and spiritual issues. Conversely, confrontation, critical
and rejecting attitudes, impersonal treatment, going through the motions,
emotional absence, and hiding things were counterproductive.
The implications for practice are that therapists need to be attuned
to their clients’ varying needs throughout therapy while being adaptively
responsive to them in critical moments.
MONITORING THE RELATIONSHIP
Premise 18: The therapist continuously monitors the quality of the thera-
peutic relationship, client progress, and any strains in the relationship,
collaborating with the client to make any needed or desirable adjustments.
Along with the client’s progress or lack thereof, one important area
to monitor is a strain or rupture in the therapeutic relationship or alliance.
Research from several sources has indicated that clients’ and therapists’ views
of the same therapy are often discrepant, sometimes substantially so. As men-
tioned earlier, studies have shown that therapists are not good judges of their
own behavior and impact on the client, often overestimating their effective-
ness (Bohart & Wade, 2013; Duncan, 2010; Rennie, 2002). Yet the responsi-
bility for monitoring the therapy falls to the therapist. Monitoring should be
an ongoing part of therapy that is done at frequent intervals. Careful atten-
tion to the quality of the therapeutic relationship should be a constant part of
an ongoing dialogue, especially because clients often withhold their feelings
518 david j. cain

about the therapist and the relationship and defer to the therapist. Therapists
would do well to converse with their clients any time they sense that some-
thing is awry. Such input is especially valuable when there are perceived
strains and potential ruptures in the therapist–client relationship.
Research
Rennie’s (2002) research showed that clients often did not share their
views of the therapist or therapy. Safran, Muran, and Samstag (1994) noted
that successful therapy was often characterized by a rupture–repair cycle in
the therapeutic alliance that may occur at any time in therapy. However,
it tended to occur when the therapist began to address maladaptive client
patterns. Such ruptures may also occur as a result of therapist criticism of,
indifference to, and dislike of the client. Safran et al.’s findings suggested that
therapists should focus on their clients’ feelings about the therapy, that thera-
pists are crucial in repairing ruptures, and that failure to address such ruptures
will likely lead to increased client negativity, termination, and unsuccessful
outcomes.
Lambert and Shimokawa’s (2011) research provided substantial and
compelling evidence that monitoring the client’s progress and providing
client feedback to therapists improved good outcome while decreasing treat-
ment failure. Shimokawa, Lambert, and Smart (2010) found that rates of
client deterioration could be reduced from a baseline of 20% to 13% when
therapists were informed of client progress status. Such interventions also fur-
ther reduced deterioration rates by 5.5% while doubling positive outcomes.
Although it may take some time, effort, and courage for therapists to assess
how therapy is going from the client’s perspective, such information is vital
in keeping the therapy on track and thriving (see also Chapter 2).
PRAGMATISM, PLURALISM, AND INTEGRATION
Premise 19: The therapist brings forth for the client’s consideration any
and all personal and professional resources that may be of value to the
client.
Clients want and deserve to have available to them all aspects of the
therapist’s personal qualities, skills, professional knowledge, and resources,
just as one should expect no less from one’s physician. When clients come to
therapy, they typically indicate that they hope the therapist will understand
them, be supportive and caring, help them understand themselves, and deal
effectively with their concerns. They often express a desire to develop some
strategies to help them cope and function better. In some cases, clients do not

know what they need to help them think, feel, and do better, but they cer-
tainly recognize what is helpful and what is not. Thus, humanistic therapists
would be wise to depend on their clients to make choices about, and assess
the value of, whatever their therapists might offer.
Although I fully believe that therapists should be grounded in their
therapeutic beliefs and values, theoretical allegiance should not ever limit
therapists from doing what is in their clients’ best interests. As mentioned
previously, there are problems for which humanistic therapies are not ideally
suited (e.g., some anxiety problems), at least not without supplementation or
modification. I contend that therapeutic pragmatism, or doing what works,
is a moral and professional responsibility, because clients’ primary concern is
whether the therapist can assist them with their problems. This implies that,
to be maximally effective, therapists need to become more integrative of both
theory and practice aspects of multiple models of psychotherapy.
Integration represents the present and future of optimally effective psy-
chotherapies, including humanistic versions. It is clear by now that no single
approach to psychotherapy has demonstrated superiority over any other estab-
lished therapeutic system. Nor has any system shown superiority in effective-
ness with clients with specific problems (e.g., depression), despite claims to the
contrary. If there is anything in the field of contemporary psychotherapy that
approaches a near-universal truth, it is that all schools of thought are flawed,
limited, or insufficiently developed in both theory and practice. A problem
with any model of psychotherapy is that it inevitably has limitations in its
effectiveness with some significant portion of clients when practiced in its tra-
ditional manner. Consider that research has shown that roughly 20% to 50%
of clients, depending on their form of psychopathology, do not benefit from
psychotherapy. Ideally, recognizing the limitations of one’s approach should
impel practitioners to engage in critical analysis of their theory and its manner
of implementation, with an eye to modifying and refining it.
Doing what works or what is in the best interests of a given client may
take various forms. Barry Duncan, author of On Becoming a Better Therapist
(2010), noted that optimally functioning therapists draw from several models
of psychotherapy and urged therapists to be “theoretically promiscuous” (p. 14).
Theoretical integration, which goes beyond a blending of techniques, strives to
create a conceptual framework that synthesizes the best elements of two
or more approaches [and] . . . aspires to more than a simple combination;
it seeks an emergent theory that is more than the sum of its parts, and
that leads it in new directions for practice and research. (Norcross &
Newman, 2005, pp. 12–13)
Because therapists’ fundamental commitment is to their clients’ well-
being, it is appropriate and desirable that they bring forth their perspectives,
520 david j. cain

values, beliefs, perceptions, knowledge, relational skills, and therapeutic
processes and procedures for their clients’ consideration. As collaborative
partners, therapists offer, but do not insist on, whatever they believe may be
of most value to their clients. Such a therapeutic approach would be more cli-
ent directed and client informed and, thus, truly more client centered in the
sense that the client is always an active and agentic participant in the therapy.
In this approach, therapists are free to offer noncoercively whatever they
believe to be in their clients’ best interests, and clients are ultimately free to
choose what fits and reject what does not.
Research
Research on integrative approaches to psychotherapy is relevant to the

therapist’s pragmatic use of theoretical concepts and pluralistic practices from
other approaches. There is modest but growing evidence supporting integra-
tive practices.
Goldfried, Glass, and Arnkoff (2005), experts in the integrative move-
ment, provided empirical support for the effectiveness of four integrative
approaches: (a) assimilative, (b) sequential and parallel–concurrent, (c) theo-
retical, and (d) technical eclectic. In the assimilative approach, a primary
therapy is supplemented with specific techniques from other approaches. In
this approach, research-based support may come from mindfulness-based cog-
nitive therapy for depression, emotion-focused individual therapy, emotion-
focused couples therapy, integrative cognitive therapy for depression, and
functional analytic therapy. In the sequential and parallel-concurrent approach,
two modalities are used in sequence (e.g., psychoanalytic followed by behav-
ioral). In this model, for example, there is support for cognitive–behavioral
plus interpersonal–emotional processing therapy for general anxiety dis-
order. In the theoretical integration approach, a specific theory guides the
choice of interventions drawn from one or more systems of psychother-
apy. Empirical support exists for acceptance and commitment therapy,
cognitive–analytic therapy, dialectic behavior therapy, multisystemic ther-
apy, and transtheoretical therapy. The technical eclectic model integrates
techniques from various approaches without regard for their theoretical ori-
gins. Lazarus’s (2005) multimodal therapy has modest support, and Beutler
and Harwood’s (2000) model that uses systematic treatment selection has
strong empirical support.
Indirect support for integrative therapies comes from the research sup-
porting cognitive–behavioral therapy, which is an increasingly integrative
approach. Lambert and Ogles (2004) suggested that “integrative therapies
may increase therapy effect sizes through more broad effects, fewer dropouts,
and the like” (p. 177).

Finally, because eclectic and integrative therapies are more dominant in
practice (they are now used by one half to two thirds of practitioners) than are
the major schools of psychotherapy (Lambert, 2013), it seems fair to suggest
that integrating concepts and methods from various therapeutic approaches
represents therapists’ best attempts to do whatever is in their clients’ best
interests. That said, I believe that the core values of relational emphasis and
emotion focus of humanistic psychotherapies make them ideally suited to
serve as a sound integrative base for all approaches to psychotherapy. The
core conditions of therapist empathy, positive regard, and authenticity are
fundamental to all effective therapy. The importance of therapist presence,
focus on the client’s subjective reality, trust in and reliance on the client’s
resourcefulness and agency, focus on the self, and emphasis on helping clients
find meaning and purpose in their lives all enhance the effectiveness of all
therapeutic practices.
THERAPIST INVESTMENT IN CLIENT WELL-BEING
Premise 20: The therapist is invested in the client’s therapeutic progress

and well-being.
Therapeutic wisdom and experience suggest that most clients care a
great deal about how invested their therapists are in them and their well-
being. They appreciate knowing that they matter to their therapists and
feel cared about. Clients are more likely to thrive when their therapists are
invested and sense quite keenly when such investment is present and when
it is not. In contrast, when therapists’ investment is experienced as limited,
inconsistent, or compromised, clients are often aware of it. They may feel
that the therapist is going through the motions or that they are just another
client or a source of income. They may notice that their therapist is not fully
present with them, but rather seems preoccupied, distant, uninvolved, has
low energy, or more technical than relational in their manner.
Therapist investment is defined as the therapist’s unwavering personal
and professional commitment to alleviating client distress and promoting
well-being. It embodies a combination of a caring attitude, a “being for”
the client, and a dedication to enable the client to feel better and func-
tion more effectively. Invested therapists communicate a sense of being
there for and feeling genuinely concerned about their clients. They can be
relied on to support and assist their clients in any way that seems promis-
ing. The attitude of invested and dedicated therapists is that they will
stay the course, will accompany clients through the worst of times, and
will not give up. Invested therapists’ attitudes are fundamentally altru-
istic in nature. Their clients genuinely matter to them on a personal as
522 david j. cain

well as a professional level. On the personal level, the therapist’s attitude
and communication are beyond that of professional to client because they
embrace a personal element that communicates “I value you as a person
in a personal way, in addition to my professional commitment to you.”
Thus, investment is always personal in its ideal form and involves an ele-
ment of friendship, though appropriate professional boundaries are main-
tained. Noted existential psychotherapist Irvin Yalom (2002) suggested
that therapists “let the patient matter to” them. He urged therapists to “let
them enter you, influence you, change you—and not conceal this to them”
(Yalom, 2002, pp. 26–27).
Clients’ experience of the therapist’s investment often enhances their
progress when they understand the therapist’s commitment as hopeful and
encouraging. Clients come to realize that the therapist will go the extra mile
and do whatever is necessary to assist them. When clients experience their
therapist in this manner, they no longer feel alone in dealing with their prob-
lems, knowing they have a trusted ally. Consequently, the client is likely to
feel safe and securely attached, because the therapist and client are partners
working on behalf of the client.
Therapist investment and dedication may take many forms. Some of
these include extending the session when needed, being available after hours
for telephone consultation, making home visits when clients cannot get to
the therapist’s office, checking in on a client who is ill or in the hospital,
spending time learning more about the client’s problems or how best to alle-
viate them, letting the client know that the therapist thinks about them dur-
ing the week, remembering birthdays and the dates of significant events (e.g.,
loss of a loved one), remembering important things clients have disclosed,
monitoring their own behavior, and striving to do the best job possible with
the client, among many others.
Research
Surprisingly, I could find no evidence that the variable of therapist

investment or dedication has been investigated. An inspection of the subject
index of six editions of Bergin and Garfield’s Handbook of Psychotherapy and
Behavior Change did not reveal a single entry for therapist caring, commit-
ment, dedication, or investment. This seems puzzling because therapeutic
wisdom and common sense suggest that such therapist attitudes and behav-
iors contribute in meaningful ways to solidifying the therapeutic alliance,
reducing clients’ distress, and enabling them to move forward in their lives.
The lack of research on this variable seems even more puzzling when one con-
siders that clients’ self-reports often identify therapist caring as very impor-
tant to them. Therefore, it would seem highly desirable that psychotherapy

researchers put to the test the compelling premise that the quality and degree
of therapist investment are associated with positive outcome.
PUTTING IT ALL TOGETHER
In the past few decades, both researchers and practitioners have come to
understand that the primary agent of therapeutic change is the client. When
clients are active and involved participants in therapy, they are likely to
profit from what the therapist provides and the quality of their relationship.
Therefore, therapists need to do whatever they can to increase and maintain
client involvement. Clients who are receptive, open, and nondefensive are
apt to disclose and explore troublesome aspects of their selves and lives. They
are more likely to attend to, express, process, and learn from their emotions,
especially when their therapist is attuned to their emotions and supports and
guides them in doing so. When clients function from an internal locus of
control and evaluation, they are more likely to develop a sense of confi-
dence in themselves and their capacity to use sound judgment and engage in
healthy decision-making processes. As they focus on themselves and various
subselves or voices, they become clearer about and redefine who they are in
more positive and congruent ways, functioning in a more integrated manner.
Better connection and communication with and between clients’ subsystems
result and, consequently, they have more experiences of feeling whole and
efficient in their functioning and in relationships with self and others. Their
sense of self-efficacy also increases.
Clients, of course, engage in and benefit most from therapy when they
are motivated or sufficiently distressed in an area they deem personally rel-
evant, along with being desirous of change. That said, there are times when
clients need therapist assistance in identifying problematic areas, in finding
intrinsic motivation for change, and in becoming aware that some area of
their life is more in need of change than they had previously recognized.
Therapists, of course, play a crucial role in how well clients benefit
from therapy. An enormous and growing body of research has shown that
the quality of the therapist–client relationship serves as a foundation for
change. At times, it is sufficiently powerful to create transformative moments
or significant shifts in the way clients see themselves and others and, con-
sequently, in how they deal with their lives. Perhaps the quality that most
grounds therapy and lends power to a wide range of relational qualities is
presence. When experiencing high levels of presence, therapists are focused
and immersed in their clients, are for them and with them, and are invested
in their progress and well-being. Therapist presence contributes substantially
to the therapist’s and client’s capacity to meet at relational depth and engage
524 david j. cain

in more meaningful dialogue. The quality of therapists’ presence lends power
to almost everything the therapist does in the therapeutic endeavor.
Therapist empathy remains the most critical variable in good out-
come. Empathy creates a sanctuary where clients can be themselves and
explore themselves. It stimulates intrapersonal and interpersonal learning
and fosters clarity. Humanistic therapists focus on their clients’ subjective
reality, with a desire to understand what it is like to be them. When clients
experience their therapists as understanding, their therapists’ acceptance,
regard, and affirmation have a greater impact, which is further enhanced
when the therapist is experienced as real and trustworthy. Feeling accurately
understood and accepted for who they are enables clients to see themselves
in more positive ways, while reducing anxiety about their deficiencies and
limitations. As clients’ views of self are enhanced, they are more likely to
behave in a manner more consistent with their revised view of self and
become more confident in their abilities. When therapist and client are
mutual in their liking and affirmation, their bond is strengthened. This, in
turn, enables clients to tolerate difficult moments in therapy and reduce the
likelihood of a rift or rupture in the relationship. The quality of the bond
or alliance is also a factor that enables therapist and client to persevere
through rough spots. The therapist qualities discussed above also contribute
to the strength of the therapeutic alliance, which is itself a good predictor
of successful outcome.
The ways in which therapists view their clients have a lot to do with
how they engage with them. When therapists view clients as resourceful
or actualizing people, they bring positive expectation and optimism to the
therapy. They are then more likely to remain hopeful about clients’ capacity
to right themselves when the going gets rough. At such times, it is especially
important to clients to feel that therapists are invested in their well-being
and maintain their faith in their ability to change and that they will not give
up on them.
Focusing on clients’ emotions and assisting them to express, process, and
reflect on the personal learning that evolves from doing so are now under-
stood to be among the most promising ways to effect constructive change.
Therapeutic learning that is likely to endure is felt in one’s bones while also
making good sense cognitively and behaviorally. It is also clear that therapy
is likely to be more effective when therapists focus on clients’ internal subjec-
tive reality, on clients’ self and self-efficacy, and on enhancing clients’ agency
and the development of an internal locus of control and evaluation. When
this happens, clients are more likely to identify principles by which they
want to live that fit their fundamental values, beliefs, and personality. As this
occurs, clients gradually learn to be their own therapists, a goal that therapists
would be wise to embrace as a marker of effective therapy.

It has become increasingly clear over the past few decades that thera-
pists do not just provide treatment methods or relational conditions that
result in good outcomes for the client. Instead, it is now understood that
therapist and client are part of a field in which each continually influences
the other. In this view, therapist and client are, in a sense, cotherapists who
work in a cooperative and collaborative manner in cocreating the course
of therapy. Therefore, whatever the therapist does is not likely to have a
completely predictable and linear effect on the client. How clients respond
affects their therapist, who, in turn, may respond in the same or a differ-
ent manner, depending on how the therapist was affected by the clients’
responses. Simply put, what transpires in therapy is much more complex
than what meets the eye or what might be predicted by one’s theory. It is
quite difficult, then, to make accurate a priori “if–then” predictions about
the effects of a particular approach or manner of relating. Instead, therapy
will benefit from the therapist and client becoming coobservers of how the
therapy is progressing. In this context, it seems more desirable to ponder
and ask “how are we doing?” because therapy is a two-person endeavor. Of
course, it also makes sense for therapists to assess on their own how they are
doing and for clients to do the same because each contributes separately and
jointly to therapy progress.
Therapy is optimized when therapist and client work as collaborative
partners to individualize each course of therapy in terms of the definition of
the client’s problems, goals, means to reach them, and the kind of relation-
ship and responsiveness that work best for the client. When therapy bogs
down, it is essential that therapists and clients work together to assess what is
not working or is counterproductive and that therapists nondefensively take
clients’ concerns seriously and modify their approach in a manner that is
more effective. To be maximally effective, therapists need to be open minded
enough to recognize when their theoretical approach is not adequate as cur-
rently practiced. At such times, therapists need to be sufficiently adaptive and
accommodative in whatever ways are in the client’s best interests. In other
words, being pragmatic or doing what works trumps allegiance to theory.
Therapists need to bring forward aspects of themselves, methods, a quality of
relationship, and information that fit the clients’ current needs. Increasingly,
effective therapists have begun to integrate concepts and methods from other
therapeutic approaches to the benefit of their clients. Integration shows enor-
mous promise to improve outcome, because it broadens the range of thera-
pists’ thinking about therapy and the range of their responsiveness.
The responsibility for monitoring the success of therapy, or lack thereof,
falls squarely on therapists’ shoulders because clients tend to defer to them
and fail to disclose their discontents. Therefore, frequent assessments, for-
mal and informal, go a long way toward assessing what is going wrong and
526 david j. cain

adjusting the therapy accordingly. Doing so will reduce the dropout rate and
get therapy back on track while repairing strains in the relationship and pre-
venting irreparable ruptures.
Finally, although much remains to be learned about how therapies work
in effecting change, we have now accumulated sufficient data from a human-
ist perspective to provide sound guidelines for practice. I hope that others
will review with open and critical eyes what I have proposed and continue
to modify or refine it in the light of the new evidence that will inevitably be
generated by new research.
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Index
Abeles, N., 458 Task Force on Empirically Supported

Abramowitz, C. V., 514 Therapy Relationships, 423
Abramowitz, S. I., 514 Task Force on Evidence-Based
Academic problems, 399–400 Practice, 54
Acceptance, 6, 495–497 Task Force on Evidence-Based
Acceptance and commitment therapy Therapy Relationships, 298
(ACT), 235–237, 242 Task Force on Promotion and
Accordino, M. P., 362 Dissemination of Psychological
Active engagement, 458 Procedures, 62
Adams, K. E., 334 Ametrano, R. M., 469, 508
Adams, M., 286 Anderson, M. Z., 473
Adaptive functioning, 148–149 Anderson, T., 469
Addictions, 120 Anger
ADHD (attention-deficit/hyperactivity arousal with, 155–156
disorder), 395 assertive, 154
Adler, A., 495 management of, 172
Aesthetic contacting (Gestalt therapies), transformation of, 164–165
226 Angus, L. E., 333, 464, 471, 493
Affective empathy, 116 Anxiety disorders
Affective neuroscience, 147, 159 and client expectations, 471
Affect regulation, 135 emotion-focused therapy for, 329
Affirmation, 459, 495–498 humanistic therapy vs. CBT for
Agency treatment of, 58–59
defined, 322 mindfulness techniques for, 235
in existential therapies, 305 Anxious attachment, 473
in Gestalt therapies, 223, 230 Aoki, T., 265, 266
and nondirectivity, 189 APA. See American Psychological
and qualitative research, 85, 93, Association
97, 100 Appreciative inquiry, 81
in solving emotional problems, 168 Arch, J. J., 235
and therapeutic change, 156 Arizmendi, T. G., 459, 509
Agoraphobia, 58 Armstrong, M. S., 265
AIRM (attachment injury resolution Arnkoff, D. B., 469, 508, 521
model), 366–368 Arnt, J., 33
Aked, J., 16 Art therapy, 261
Alarm signals, 66–68 Asay, T. P., 423
Alcohol disorders, 120 Ask the Expert, 474
Alegria, S., 287, 289, 293 Assimilative approach to therapy, 521
Alexithymia, 152–153 Attachment focused family therapy, 360
Allen, Frederick, 186 Attachment injury resolution model
Altruism, 296 (AIRM), 366–368
American Psychological Association Attachment theory, 15, 472–473
(APA) Attention-deficit/hyperactivity disorder
and evidence-based treatments, 57 (ADHD), 395
Society for Clinical Psychology, 513 Attuned listening, 492–493
537
Austin, S. B., 64, 429, 500 Berman, M. I., 236
Auszra, L., 465 Bernecker, S. L., 472
Authenticity, 31–36 Beutler, L. E., 227, 459, 469, 509, 521
defined, 31 Binder, P. E., 463
in existential therapies, 299 Binswanger, L., 14
measurement of, 32 Blanco, P., 395, 399
overview, 498–501 Blatt, S. J., 432
research on, 35–36 Bohart, A. C.
and social functioning, 33–35 and collaboration in therapy, 474, 477
and well-being/mental health, 32–33 and empathy, 116, 123, 424, 428, 494
Authenticity Inventory, 32 and optimal practices of humanistic
Authenticity Scale, 32 therapies, 486, 487, 504,
Autonomous motivation, 468–469 507–509, 517, 518
Autonomy, 12, 31, 191, 506, 507 and person-centered therapy, 187,
Aviram, A., 471 188, 192
Avoidant attachment, 473 and therapy outcomes, 456, 457
Awareness events, 98–99 Bolger, N., 21
Axline, Virginia, 388–389, 399 Bona fide treatments, 54, 199
Bordin, E., 425
Bachelor, A., 121, 516 Boritz, T. Z., 333
Badenoch, B., 404 Bostrom, A., 200
Baggerly, J., 401 Boudewyn, A. C., 200
Bahramabadi, M., 405 Boundary situations, 283
Baldwin, S. A., 427, 434, 503 Boutelle, K. N., 236
Baliousis, M., 32 Bowlby, J., 15, 356
Bandura, A., 513, 515 Bozarth, J. D., 195, 209
Barkham, M., 198 Bradley, B., 366
Barnes, M., 471 Branigan, C., 163
Barrett, M. S., 500–501 Bratton, S., 391–395, 397, 400, 406
Barrett-Lennard, G. T., 116, 119, 121, Breitbart, W., 295, 307
135–136, 191 British school of existential analysis,
Barrett-Lennard Relationship Inventory, 286, 296–297, 300, 303
63–64, 119, 121, 330 Brown, A. G., 401
Baumeister, R. F., 22 Brown, L. S., 91
Bayat, M., 397, 406 Buber, M., 14, 91, 202, 221, 290, 299, 305
Beauregard, A. M., 469, 506 Bugental, James, 295
Becker-Weidman, A., 369 Burkard, A. W., 468
Bedard, D. L., 154, 332 Burlingame, G., 402
Beebe, J., 460 Bushman, B. J., 156
Behavioral experimentation, 235, 242 Butler, J. M., 460, 509
Behavioral therapy, 150–151. See also Butollo, W., 233, 242
Cognitive–behavioral therapy
Beisser, A., 225 Cain, D. J., 12, 26, 188, 192
Bergen-Cico, D., 235–236 Callahan, J. L., 471, 517
Bergin, A. E., 51, 61, 422, 455, 505 Carryer, J. R., 156, 333
Bergin and Garfield’s Handbook of CAS (“Clearing a Space”), 262–264,
Psychotherapy and Behavior Change, 266–269
197, 198, 523 Cassens, J., 460
Berkowitz, L., 155 Castonguay, L. G., 503
Berman, J. S., 121, 500–501 CBT. See Cognitive–behavioral therapy
538 index

CCPT. See Child-centered play therapy Client-centered therapy. See Person-
Chagigiorgis, H., 65 centered therapy
Chair work, 193, 227. See also Empty- Client role involvement, 506
chair method Client–therapist relationship. See
Chambless, D. L., 53, 57 Therapist–client relationship
Chamodraka, M., 462, 503 Client variables, 455–478
Change (client process) attachment style, 472–473
client perspectives of, 462–465 client expectations, 470–471
empathy as active ingredient of, 117 client participation/engagement/
in focusing-oriented–experiential involvement, 457–459,
therapy, 252–253 474–475
humanistic therapy’s influence on, 6 client perspectives of change, 462–465
readiness for, 486–489 clinical application of research on,
from therapeutic relating, 14 473–477
types of, 515 collaboration, 471–472
Cheon, S., 235–236 depth of experiencing, 459–468
Cheung, M., 234 early research on, 456–457
Child-caregiver relationships, 400–401 motivation, 468–469
Child-centered play therapy (CCPT), positive view of self, 468
387–412 recent research on, 461–473
for academic and language issues, resistance, 469–470
399–400 Clinical Support Tool (CST), 68
case example, 407–411 Cloutier, P. F., 364
characteristics of, 388 Cognitive–behavioral therapy (CBT)
for child-caregiver relationships, for anxiety disorders, 58–59
400–401 chair work in, 227
early research on, 390–392 for chronic fatigue syndrome, 236
for externalizing and disruptive for complex trauma, 158
behaviors, 394–397 and early research on humanistic
and filial family therapy, 358, 361 psychotherapies, 52
for internalizing disorders, 397–399 emotion-focused therapy vs., 328
recent research on, 392–407 empathy in, 118
recent topics of focus in research on, experiential person-centered therapy
402–404 vs., 433
review of recent research on, 404–407 Gestalt therapies vs., 229
for self-concept and competency, increase in popularity of, 196
401–402 mindfulness-based stress reduction
therapeutic conditions for, 388–390 vs., 235–236
Child development, 403 objectivism in, 90
Childhood abuse, 325, 369 person-centered therapy vs., 199, 201
Children practices in, 426–427
focusing experience in, 270 research support for, 521
humanistic psychotherapy with. See therapeutic presence in, 238
Child-centered play therapy therapist factors in, 61
Chisholm-Stockard, S., 425 therapist factors in outcomes with, 61
Chronic fatigue syndrome, 236 trauma-focused, 403
Chronic pain, 269 Cognitive dissonance, 149
Classen, C., 364 Cognitive empathy, 116
“Clearing a Space” (CAS), 262–264, Cognitive–existential group therapy, 303
266–269 Cognitive–existential therapy, 286
index 539
Cognitive processing therapy (CPT), 234 Critical consciousness, 90–91
Cognitive psychology, 13 Critical–ideological approaches
Coherence, 323–324 (qualitative research), 88–90, 104
Collaboration, therapist-client, 14, Critical psychiatry, 190
471–472, 504–505 Crits-Christoph, P., 422
Combs, A. W., 476 Crook-Lyon, R. E., 468
Communicative attunement, 428–429 Crow, S. J., 236
Competence, 12 CST (Clinical Support Tool), 68
Competency, 401–402 CT (countertransference), 437–439
Complex trauma, 156–158 Cuijpers, P., 201
Conditioning, operant, 13 Cultural competence, 91
Conflict management skills, 362–363 Curtis, R., 429
Congruence
early research on, 64 Dalgleish, T. L., 367
and empathy, 120 Dalton, J., 364
overview, 425, 429–439, 498–501 Danger, S., 400
in person-centered therapy, 191 Daniel, T., 98
qualitative research on, 95 Daseinsanalysis, 285
Connor, J., 237 Davidson, L., 431
Constantino, M. J., 464, 469, 508 Day, L., 33–34
Constructivism, 323–324 DBT (dialectical behavior therapy),
Constructivist–interpretive qualitative 235, 237
research, 86–88, 104 Deception, 34
Contacting (Gestalt therapies), 220, Deci, E. L., 191
226, 242 Decision making, 4, 148
Contextual therapy, 285 Defensiveness, 459, 508–509
Cooper, M. De la Ronde, C., 34
and existential therapies, 194, 286, Delgato-Romero, E. A., 101
305 Del Re, A. C., 62, 434, 503
and humanistic psychotherapy with Denton, W. H., 364
children, 387, 388 Depression
and person-centered therapy, 192, and anger, 155–156
198, 202 counseling for, 209
and positive regard, 431 and emotional expression, 512
and relational connection, 14 emotion-focused therapy for, 327,
and relational depth, 501 328, 332–333
Cooperation, 504–505 person-centered therapy for, 200
Correia, E., 287, 289–291, 305–306 and self-criticism, 163
Counseling and Psychotherapy: and social support, 16
Newer Concepts in Practice Derkzen, D. M., 469, 506
(Carl Rogers), 186 Description, rule of, 221, 289
Counseling for depression, 209 Desensitization, 227
Countertransference (CT), 437–439 Dessaules, A., 512
Couple and family therapies. See DET (dialogical exposure therapy),
Humanistic couple and family 233–234
therapies Dewey, J., 255
CPT (cognitive processing therapy), 234 Diagnostic and Statistical Manual of
Crago, M., 459 Mental Disorders, 60, 196, 229
Crago, S. B., 509 Dialectical behavior therapy (DBT),
Creaner, M., 64, 95, 335 235, 237
540 index

Dialectical constructivism, 323–324 Emotional intelligence, 149
Dialogical exposure therapy (DET), Emotional processing
233–234 defined, 151
Dialogical relationship, 221–223 in emotion-focused therapy, 332–334
Dilthey, Wilhelm, 255 overview, 29
Discourse analysis, 88 Emotional reflection, 148, 160–162
Disruptive behaviors, 394–397 Emotional transformation, 148, 162–166
Distress, 331, 486–489 Emotion-focused couples therapy (EFT-C)
Doolin, E. M., 431, 497 case illustration, 374–379
Dougherty, J., 400–401, 403 development of, 321
Doumas, D., 402 early research on, 361–362
Dowell, N. M., 121 overview, 355–357
Dulsky, S., 391 recent research on, 364–368, 513
Duncan, Barry, 520 Emotion-focused family therapy, 359–360,
Dyadic developmental psychotherapy, 368–369
360, 369 Emotion-focused therapy (EFT), 319–344
Dymond, R. F., 515 basic principles of, 322–325
Dysfunction, 325–326 bodily experiences in, 172
chair work in, 227
Efron, D., 368–369 clinical applications of research on,
EFT. See Emotion-focused therapy 336–343
EFT-C. See Emotion-focused couples development of, 162
therapy early research on, 327
Elliott, R. empathy in, 119
and emotion-focused therapy, 321, for families, 359–360, 368–369
327, 329, 336 integrative aspects of, 6
and empathy, 120, 424, 494 overview of research on, 511–513
and existential analysis, 303 principles in, 163
and Gestalt therapies, 227, 234 recent research on, 328–336
and humanistic therapy processes for relational trauma, 152–153
and outcomes, 52–56, 59, structure of, 326–327
62, 74 techniques of, 150
and motivational interviewing, 488 theoretical evolution of, 320–321
and optimal practices of humanistic as tribe of person-centered therapy,
psychotherapies, 511 191, 193
and person-centered therapy, 197–200 view of dysfunction in, 325–326
and philosophical principles of Emotion regulation, 4, 148, 157–160,
humanistic therapies, 387 237, 326
and qualitative research on humanis- Emotion scheme, 162
tic psychotherapy, 94–98 Emotions in psychotherapy, 26–31,
and revival of person-centered 147–175
therapy, 405 activation of, 155–157
and therapeutic alliance, 437 and adaptive functioning, 148–149
and therapist factors, 428, 431, 462 benefits of, 28–30
Ellison, W. D., 472 change with, 162–169
Embodied cognition, 219–220, 222 in group psychotherapy, 296
Emotional arousal and enactment, 148, humanistic–experiential principles
155–157, 165, 167, 332–334 for, 166–175
Emotional awareness and engagement, importance of, 4
148, 151–155 information conveyed with, 149–151
index 541
Emotions in psychotherapy, continued Existential analysis, 286
reflection on, 160–162 Existential analytical psychotherapy, 286
regulation and soothing of, 157–160 Existential experimentalism, 224–226
research on, 30–31 Existential–humanistic therapies,
and self-concealment, 27–28 295–296
and self-disclosure, 27 Existentialism
therapeutic strategies for getting in concepts in, 5
touch with, 151–155 loss of meaning in, 325
Emotion structure, 150 in person-centered therapy, 193–194
Empathic communication, 116 Existential person-centered therapy, 191
Empathic conjecture, 126 Existential–phenomenological therapy,
Empathic doubling responses, 126 286
Empathic evocations, 125 Existential psychotherapies, 283–310
Empathic exploration responses, 125 future directions for research on, 309
Empathic rapport, 428 general practices of, 286–293, 297–300
Empathic refocusing responses, 126 key branches of, 293–297
Empathic resonance, 116, 121 meaning-oriented practices in,
Empathic understanding responses, 125 306–308
Empathy, 115–136 outcome research on, 284, 300–304
affective, 116 prominence of, 6
affect-regulating function of, 135 scope of, 284–286
case study, 129–134 therapeutic relationships in, 305–306
cognitive, 116 EXIST project, 300–302
deconstructive function of, 135 Expectations, client, 470–471
definitions of, 115–116 Experiencing (therapy process), 459–461
early research on, 63–64, 117–118 defined, 255
importance of, 4, 6 in emotion-focused therapy, 331–332,
interpersonal function of, 134–135 511–512
overview, 424, 431–439, 492–495 and expressiveness, 460
perceived, 116 in Gestalt therapies, 220
person, 116, 429 in humanistic couple and family
in person-centered therapy, 190–191 therapies, 362
received, 116 and locus of control, 461
in relationship enhancement measurement of, 153–154
therapy, 355 overview, 459–468, 510–513
review of recent research on, 118–125 with process-guided focusing, 65
self-, 136 Experiencing Scale (EXP), 251, 260–262,
and strengthening of self, 135–136 320, 332, 362
types of therapist responses invoking, Experiential approaches
125–129 in emotion-focused therapy, 320
Empty-chair method, 65, 227, 327, in person-centered therapy, 191, 194
329, 334 Experiential–existential group psycho-
Epistemology, 83 therapy, 286, 296
Epoché, rule of, 221, 289 Experiential–existential therapy,
Epstein, L., 200 302–303
Eubanks-Carter, C., 435 Experiential–humanistic approaches.
Everall, R. D., 494–495 See Emotions in psychotherapy
Existence: A New Dimension in Psychiatry Experiential psychotherapy, 254. See
and Psychology (R. May, E. Angel, Focusing-oriented–experiential
& H. F. Ellenberger), 295 therapy
542 index

Exposure techniques, 150–151, 233–234 Foerster, F., 65
Expressiveness, 460, 509 Foon, A. E., 514
Externalizing behaviors, 394–397 Foresight Report, 15
Eye movement desensitization and Fosha, D., 168
reprocessing, 158, 172 FOT. See Focusing-oriented–experiential
therapy
FACT–B (Functional Assessment Frankl, Viktor, 294, 307
of Cancer Therapy for Breast Frantz, S. H., 67
Cancer), 268 Frederickson, B. L., 163
Fall, M., 395 Freedom, 5, 305
Falzer, P., 431 Freire, E., 53
Farahzadi, M., 405, 406 Freud, Anna, 388
Farber, B. A., 424, 431, 473, 497 Friedlander, M. L., 464
Fear, 164 Friedman, M., 14, 499
Felt sense, 460 Friere, E., 387
Feminist models for qualitative research, Frijda, N. H., 150
88, 89 Fukumori, H., 265
Ferraro, M., 269 Functional Assessment of Cancer
Field, C., 429 Therapy for Breast Cancer
Filak, J., 458 (FACT–B), 268
Filial family therapy, 358–361 Functional Assessment of Chronic
Fischer, C. T., 91 Illness Therapy—Spiritual, 268
Fitzpatrick, M. R., 462, 503 Furrow, J. L., 366
Flahive, M.-H. W., 395, 397
Flückiger, C., 62, 434, 503 Galinsky, A. D., 33
FMS (Focusing Matter Scale), 265–267 Garcia, R., 402
Focusing Garfield, S. L., 51, 455, 456, 505
defined, 254 Garza, Y., 395, 397, 406
exercise for, 165, 193 Gaston, L., 502
and felt sense, 460 Geller, M., 491
therapist, 270–271 Geller, S. M.
Focusing attitudes, 266 and empathy, 119
The Focusing Institute, 270 and Gestalt therapies, 222, 235, 237,
Focusing Matter Scale (FMS), 265–267 238, 241
Focusing-oriented–experiential therapy and humanistic therapy processes
(FOT), 251–276 and outcomes, 63
background of, 254–258 and person-centered therapy, 202
bodily experiences in, 172 and therapeutic alliance, 330
“Clearing a Space” protocol in, and therapeutic presence, 433
262–264, 266–269 Gelso, C. J., 430, 438
client change process in, 252–253 Gendlin, E. T., 460
clinical applications of research on, and emotional processing, 509
271–275 and emotions in psychotherapy,
and Experiencing Scale, 251, 260–262 148, 149, 153, 157–158,
recent macroprocess research on, 165, 170
264–266 and focusing-oriented–experiential
recent microprocess research on, therapy by, 254–256, 258–259,
266–271 263, 275
as tribe of person-centered therapy, and process-guided focusing, 65
191–193 and view of blocked process, 325
index 543
Generalized anxiety disorder, 58, 329. Gone, J. P., 89
See also Anxiety disorders Gonzalez, D. M., 476
Genuineness Goodkin, D. E., 200
importance of, 6, 91 Gormley, B., 473
overview, 425, 429–439, 498–501 Gottman, J. M., 357–358
and therapy effectiveness, 429 Gottman, J. S., 358
Gervaize, P. S., 512 Granger, D. A., 390–391
Gestalt therapies, 219–243 Grant, B., 187
chair work in, 193 Grawe, K., 424, 455–456, 491–492
clinical applications of research on, Greaves, A. L., 503
239–242 Greaves Wade, A., 477
conflict in, 173 Greenberg, L. S.
early research on, 226–227 and client variables, 457, 465–466
emotion in, 150 and emotion-focused couples therapy,
existential ideas in, 285 355–357, 365–368, 374
future directions for research on, 239 and emotion-focused family therapy,
Gestalt-consilient research, 235–238 359
Gestalt hybrid research, 233–235 and emotion-focused therapy,
Gestalt-specific research, 228–232 320–321, 331–334
integrative nature of, 220 and emotions in therapy, 148, 150,
intentionality in, 161 153, 155, 156, 164
play therapy, 405 and empathy, 116, 123, 124, 424, 494
prominence of, 6 and Gestalt therapies, 222, 234, 235,
theoretical background, 220–226 237, 238, 241
therapist–client relationship in, 14, and humanistic couple and family
221–222 therapies, 361
Giacomo, D., 461, 514 and humanistic therapy processes
Giblin, P., 360 and outcomes, 51–53, 62, 65
Ginott, Haim, 389 and optimal practices in humanistic
Giordano, M., 395 therapies, 511, 512
Glass, C. R., 469, 508, 521 and person-centered therapy, 197–199
Glass, G. V., 196 and philosophical principles of
Gleason, M. E. J., 21 humanistic therapies, 387
Golden, R. N., 364 and qualitative research, 85, 97
Goldfried, M. R., 503, 521 and therapeutic presence, 433, 491
Goldman, B. M., 32 and therapist factors, 428
Goldman, R. N. Greenman, P., 364
and client variables, 465–466 Grief, 154
and emotion-focused couples therapy, Grote, B., 517
356–357, 374 Grounded theory research
and emotion-focused therapy, 331, 335 contributions from, 102
and focusing-oriented–experiential early, 92–94
therapy, 261 humanistic psychologists’ involvement
and Gestalt therapies, 234 in, 81, 86, 87
and humanistic therapy processes on therapist factors, 431
and outcomes, 62 Group psychotherapy
and optimal practices of humanistic cognitive–existential, 303
psychotherapies, 512 existential–humanistic, 295–296
Goldstein, Kurt, 223 experiential–existential, 286, 296
Gomes-Schwartz, B., 458 meaning-centered, 295
544 index

Guba, E. G., 82 Human Change Processes (Michael
Gubi, P. M., 431 Mahoney), 493
Gudelj, L., 231 Humanistic couple and family therapies,
Guerney, B. G., Jr., 354–355, 358, 362 336–379
Guerney, Louise, 358 case illustration, 374–379
Gurman, A. S., 63–64, 353 clinical applications of research on,
369–379
Hahlweg, K., 361 dyadic developmental psychotherapy,
Hall, I., 65 360, 369
Halvorsen, M. S., 468 early research on, 360–362
Ham, J., 124 emotion-focused couples therapy,
Han, S. S., 390–391 321, 355–357, 361–362,
Handbook of Psychotherapy and Behavior 364–368, 374–379, 513
Change, 50, 51, 53 emotion-focused family therapy,
Hansen, N., 66 359–360, 368–369
Harter, S., 32 filial family therapy, 358–361
Harwood, T. M., 469, 521 Gottman’s method for, 357–358
Hatfield, D., 67 historical and theoretical overview
Hayes, A. M., 503 of, 354–360
Hayes, J. A., 120, 438 recent research on, 362–369
Heatherington, L., 464, 465, 475 relationship enhancement therapy,
Heidegger, M., 224, 255, 297 354–355, 360–363, 369–374
Heller, D., 33 Humanistic–integrative therapies, 6
Helping relationships, 190–191 Humanistic psychotherapy, 11–37
Hendricks, M. N., 172, 227, 260, authenticity in. See Authenticity
262, 509 for children. See Child-centered play
Henkel, C., 233 therapy
Henson, R. K., 401 definitions of, 4–5
Herrmann, I. R., 465 emotional expression and
Hess, S. A., 468 processing in. See Emotions
Hicks, J. A., 33 in psychotherapy
Hill, C. E., 84, 468, 501 optimal practices of. See Optimal
Hiramatsu, K., 261 practices of humanistic
Hixon, J. G., 34 psychotherapies
Holgersen, H., 463 prominence of, 6–7
Holistic perspectives, 5, 231, 387, 403 and received support, 20–26
Hölldampf, D., 393 relational connection and mental
Holliman, R., 399 well-being in, 13–20
Hollis-Walker, L., 333 research on. See Research on
Hollon, S. D., 53, 57 humanistic psychotherapies
Holman, J., 469 and self-determination theory, 12
Holowaty, K. A., 467 Human science. See Qualitative research
Holt-Lunstad, J., 17 Husserl, Edmund, 221
Hope, 230, 507–508
Horizontalization, 221, 289 Ide, T., 267
Horvath, A. O., 62, 63, 434, 503 Identification, 116
Howard, K. I., 496 Iida, M., 21
Howell, R., 514 I–It modality, 221–222
Howie, L., 230–231 Ikemi, A., 261, 265, 266
Hughes, D. A., 360 Imaginary dialogues, 165
index 545
Imel, Z. E., 427, 434, 503 Kelly, T., 230–231
Individualization of psychotherapy, Kennedy-Moore, E., 29
516–517 Kernis, M. H., 32
Insight, client Kifer, Y., 33
intentionality vs., 161 Ki Leung, T. Y., 230
qualitative research on, 98–99 Kilmann, P., 514
Instrumental emotions, 357 King, L. A., 33
Instrumental nondirectivity, 187 Kirschenbaum, H., 500
Integrative approaches, 5–6, 191–193, Klagsbrun, J., 263, 268
519–522 Klein, M., 460
Integrative person-centered therapy, 191 Klein, M. H., 64, 425, 429, 460, 500
Intentionality, 161 Klein, M. J., 462
Internal coherence, 160 Knaan-Kostman, I., 429
Internal focus, 167 Knez, R., 231
Internalizing disorders, 397–399 Knox, R., 299
International Children’s Focusing Knox, S., 468, 501
Conference, 270 Kohut, H., 116
Interpersonal connection. See Kolden, G. G., 64, 425, 429, 500
Relational connection König, J., 233
Intersubjective theory, 293 Korman, L. M., 511
Intimacy, 14, 34 Koshikawa, Y., 267
Intuitive inquiry, 86 Krebs, P. M., 469, 488
I–Thou concept Krieger, K., 67
and authenticity, 14 Krupnick, J. L., 503
and existential therapies, 290, Kubota, S., 261
299, 305
and Gestalt therapies, 221–222 Laing, R. D., 14, 296, 297
and relational depth theory, 91, 202 Lakey, C. E., 33
Lambert, M. J., 226
Jackson, C., 514 and client variables, 455
Jadda, D., 265 and humanistic therapy processes
Janzen, J., 462, 503 and outcomes, 61, 62, 66–67
Jarry, J. L., 65 and optimal practices in humanistic
Jenkins, A. H., 100 therapies, 505, 507, 517,
Jewell, C., 431 518, 521
Johnson, S. M., 321, 355–357, 361, 364, and therapist factors, 423
365, 367, 374 Landreth, G., 390, 395, 400
Johnson, W. R., 227 Lane, J. S., 424
Jones, L., 392 Längle, Alfried, 6, 294
Joseph, S., 32, 191 Language problems, 399–400
Jourard, S. M., 262 Lashani, L., 229
Layton, J. B., 17
Kalff, D. M., 261 Lazarus, A. A., 521
Karl, R., 233 Leary, M. R., 22
Karver, M., 404 LeBlanc, M., 392
Katonah, D. G., 262, 263, 269, 275 Lee, K. R., 403
Keating, E., 335 Lee, V., 307
Keisler, D. J., 460 Leijssen, M., 269, 510
Kelly, A. C., 432 Leitner, L. M., 486
Kelly, A. E., 28 Lennox, S., 263
546 index

Lesbian, gay, bisexual, and queer (LGBQ) McMullen, E. J., 119, 154, 331, 332
clients, 101 Meaning-centered counseling/
Levenson, R. W., 358 psychotherapy, 286, 294–295
Levitt, B. E., 187 Meaning-centered group psychotherapy,
Levitt, H. M., 85, 94, 102 295
Levy, K. N., 472 Meaning-making, 148, 160–162, 286
Lewin, Kurt, 223 Meaning-oriented practices (existential
Leybman, M. J., 432 psychotherapies), 301, 306–308
LGBQ (lesbian, gay, bisexual, and queer) Mearns, D., 14, 286, 387, 388, 495, 501
clients, 101 Mellor-Clark, J., 198
Lietaer, G., 52, 193, 194, 197–199, 495 Meneses, C. W., 367, 368
Lilly, J., 402 Mental well-being, 14–20, 32–33
Lincoln, Y. S., 82 Merleau-Ponty, Maurice, 223, 255, 297
Linley, P. A., 32, 191 Messer, S. B., 464
Litter, M., 431 Meta-communication, 22–23, 94, 516
Locus of control, 461, 513–514 Michels, J. L., 425
Logotherapy, 229, 294 Michelson, A., 469
Loneliness, 16, 164 Microaggressions, 101
Lopez, F. G., 34 Miller, S. D., 507, 517
Lu, E., 94 Miller, T. I., 196
Luborsky, L., 56, 117, 422 Miller, W. R., 120, 488
Mindfulness, 235–237
Mackay, B., 231 Mindfulness-based cognitive therapy
Mahoney, Michael, 493 (MBCT), 236
Mahrer, A. R., 512 Mindfulness-based stress reduction
Makinen, J. A., 365, 367 (MBSR), 235–236
Malcolm, W., 234, 365 Mirror neurons, 121–123, 222
Maltby, J., 32, 33–34 Missirlian, T. M., 156
Mancuso, R. A., 163 Mitchell, K. M., 50
Man Leung, G. S., 230, 238, 242 Mohammadifar, M., 405
Mannix, K., 429 Mohr, D. C., 200
Manual for Therapist Focusing, 271 Monette, G., 333
Marci, C. D., 124 Monsen, J. T., 468
Markman, H. J., 361 Mood disorders, 397–399
Markus, H., 515 Moran, E., 124
Marsden-Hughes, H., 431 Moras, K., 458
Maslow, Abraham, 92, 495 Morikawa, Y., 265
Mathieu-Coughlan, P., 460 Mortality salience, 300
May, Rollo, 295 Morton, T., 390–391
MBCT (mindfulness-based cognitive Motivation, 458, 468–469
therapy), 236 Motivational interviewing, 488
MBSR (mindfulness-based stress Moustakas, Clark, 389
reduction), 235–236 Moyers, T. B., 120
McAlister, B., 66–67 Multiculturalism, 6–7
McCullough, L., 67 Muran, J. C., 68, 435, 518
McElwain, B., 284 Murayama, S., 267
McKenzie-Mavinga, I., 89 Muro, J., 395–396, 401
McKeon, Richard, 255 Murphy, D., 202
McKinnon, J. M., 366 Mutual affirmation and liking, 497–498
McLeod, J., 98, 192 Mutuality, 21–22, 202, 207–208
index 547
Nadler, W. P., 512 Optimal practices of humanistic
Narrative qualitative research, 81, 87 psychotherapies, 485–527. See
Narratives also specific main headings
coherence of, 149 acceptance, 495–497
emotional reflection with, 160 affirmation, 495–497
National Health Service, 209 client depth of experiencing, 510–513
National Institute for Clinical client distress and readiness for
Excellence, 209 change, 486–489
National Institute of Mental Health client experience of therapeutic
Treatment of Depression relationship, 517–518
Collaborative Research client involvement, 505–506
Program, 503 client locus of control and
National Institutes of Health, 92 evaluation, 513–514
Navelski, L., 395 client positive expectations and
NDST (nondirective supportive therapy), therapist optimism, 506–509
197–201 collaboration and cooperation,
Neff, K. D., 34 504–505
Neuroimaging, 365 congruence, genuineness, and
Nguyen, P., 234 authenticity, 498–501
Nielsen, G. H., 463 empathy, 492–495
individualization of psychotherapy,
Nondefensiveness, 508–509
516–517
Nondirective supportive therapy
mutual affirmation and liking, 497–498
(NDST), 197–201
overview of, 524–527
Nondirectivity, 187, 195, 203–204
positive regard, 495–497
Nonverbal behaviors, 117–118
pragmatism, pluralism, and
Norcross, J. C.
integration, 519–522
and client variables, 469
relational depth, 501–502
and empathy, 118
relationship monitoring, 518–519
and existential therapies, 285, 287,
self and self-concept, 514–516
289, 308 therapeutic alliance, 502–504
and humanistic therapies and therapist investment in client
outcomes, 62 well-being, 522–524
and optimal practices for humanistic therapist presence and engagement,
therapies, 488 489–492
Norquist, S., 458 Optimism, 4, 506–509
No-treatment control studies, 55 Orlinsky, D. E.
and client variables, 455–456,
O’Donnell, P., 66–67 458–460, 491–492, 496
Ogles, B. M., 521 and principles of humanistic
O’Hara, M. M., 486 therapies, 504–506, 508–509
O’Leary, E., 227 and therapist factors, 424
O’Leary, K. D., 120 Orr, S. P., 124
On Becoming a Better Therapist Outcome research on humanistic
(Barry Duncan), 520 psychotherapies. See also
On Becoming a Person (Carl Rogers), Research on humanistic
207 psychotherapies
Ontology, 83 and emotions. See Emotions in
Openness, 459, 508–509 psychotherapy
Operant conditioning, 13 and empathy, 119–120
548 index

on existential psychotherapies, 284, and personality development, 189–190
300–304 process-guiding approaches to, 193,
on nondirectivity, 195 199–200
Overlander, M., 460 recent research on, 197–201
relational depth in, 201–202, 207–208
Packman, J., 395, 397, 400 techniques in, 205–207
Pain, 122–124, 269 Person empathy, 116, 429
Paivio, S. C., 65, 150, 160, 329, 467, 511 Perunovic, W. Q. E., 33
Palliative care, 296 Pfeifer, N., 398, 406
Panic, 58, 336 Phenomenology, 81, 86, 221, 298
Parallel-concurrent approach to therapy, Phobias, 58, 227, 336
521 Pine, F., 201–202
Parhar, K. K., 469, 506 Pinsof, W. M., 457
Park, J., 462, 503 Pinto, D. G., 33–34
Parks, B. K., 424, 455–456, 491–492 Pluralism, 192, 322, 519–522
Participation, client, 457–459, 474–475 Pomerville, A., 94
Participatory action research, 88 Porter, C., 402
Pascual-Leone, A., 85, 153, 155, 160, Pos, A. E., 153, 331, 332, 465–466, 512
164, 331 Positive psychology, 6, 191
Pascual-Leone, J., 320 Positive regard, 495–497
Pasieczny, N., 237 early research on, 64
Pastor, R., 400, 406 and empathy, 120
Patterns of Change (L. N. Rice & in existential therapies, 298
L. S. Greenberg), 321 overview, 424, 431–439
Patterson, C. L., 469 in person-centered therapy, 189–191
Paulson, B. L., 494–495 systemic reviews of research on, 424
Pausing Inventory Categorization Postpositivist qualitative research,
System, 85 83–86
P-CT. See Person-centered therapy Posttraumatic stress disorder (PTSD)
Pennebaker, J. W., 27 cognitive processing therapy for, 234
Perceived empathy, 116 dialogical exposure therapy for,
Perceptual Congruence Scale, 265 233–234
Perls, Fritz (Frederick), 147, 150, 219, 225 exposure techniques for, 150–151
Perls, Laura, 219 Gestalt therapies for, 242
Personality, 92, 189–190 and social support, 16
Person-Centered and Experiential Pragmatism, 519–522
Psychotherapies, 11 Preacco, L., 473
Person-centered therapy (P-CT), 185–210 Preoccupied attachment, 473
conditions for, 190–191 Pretorius, G., 398, 406
for depression, 327 Primary emotions, 357
developments in, 191–192 Principled nondirectivity, 187
early research on, 50–51, 194–197 Problem-solving tools, 66–68
existential approach to, 193–194 Process–experiential psychotherapy,
existential ideas in, 285 94, 227, 238, 327. See also
experiential approach to, 191, 194 Emotion-focused therapy
and Gestalt therapy, 238 Process-guiding
history of, 186–189 and focusing, 65
integrative approaches to, 192–193 in Gestalt therapies, 226
mutuality in, 202, 207–208 to person-centered therapy, 193,
nondirectivity in, 187, 195, 203–204 199–200
index 549
Process research on humanistic Relatedness, 12
psychotherapies. See also Relational connection, 13–20
Research on humanistic and emotions in psychotherapy,
psychotherapies 168–169
and emotions. See Emotions in in humanistic psychotherapy, 14–20
psychotherapy humanistic therapy’s influence on, 6
on existential therapies, 284, 304, 309 overview of, 13–14
measurement technologies in, 90 in person-centered therapy, 207–208
on nondirectivity, 195 research on, 17–20
Prochaska, J. O., 469, 488 Relational depth
Prosser, M. C., 119–121, 154, 332 defined, 14
Psychiatry, critical, 190 overview, 387–388, 501–502
Psychoanalysis, 219 in person-centered therapy, 201–202,
Psychodrama, 285 207–208
Psychodynamic therapy, 90, 198 Relational Depth Inventory, 202
Psychoeducation, 57, 306–307 Relational skills, 291
Psychotherapy (journal), 6 Relational trauma, 152–153
Psychotherapy Process Q-Sort Manual, 287 Relationship enhancement (RE) therapy,
Psychotherapy research, 11. See also 354–355, 360–363, 369–374
specific headings Relationship monitoring, 518–519
PTSD. See Posttraumatic stress disorder Rennie, D. L., 82, 87, 92, 94, 95, 461,
Purkey, W. W., 515 516–519
Purton, C., 259 Research on humanistic psychotherapies,
49–74. See also Qualitative
Qualitative research, 81–105 research
characteristics of, 82 and alternative treatments, 56–59
clinical applications of, 101–104 applications of, 68–73
constructivist–interpretive current body of, 53–55
approaches to, 86–88, 104 early, 50–53
convergence between humanistic no-treatment and wait-list control
worldview and, 90–92 studies, 55
critical–ideological approaches to, overview of, 5–7
88–90, 104 and research on other therapies,
on existential therapies, 284 60–65
with grounded theory, 81, 86, 87, and routine monitoring, 66–68
92–94, 102 on therapeutic processes, 65–66
postpositivist approach to, 83–86 Resistance, 120, 469–470
recent reviews on psychotherapy Responsiveness, 14
research, 94–101 Responsivity, 22
RE (relationship enhancement) therapy,
Raimy, V., 515 354–355, 360–363, 369–374
Ralston, M., 65 Rhine, T., 392
Rapport, empathic, 428 Rice, K. G., 34
Raskin, N. J., 186–187, 514 Rice, L. N., 162, 320, 460, 509
Raue, P. J., 503 Richmond, C. J., 473
Ray, D. C., 391–393, 395–397, 399–403 Riess, H., 121
Reactance, 469 Rimes, K., 236
Received empathy, 116 Ritchie, M., 392
Received support, 20–26 Roback, H. B., 514
Redecision theory, 227 Robinson, Virginia, 186
550 index

Rogers, Carl Saadati, H., 229
on authenticity, 499 Sachse, R., 261, 494
and changes in self, 515 Safran, J. D., 68, 425, 426, 435, 436, 518
and client distress, 486 Samstag, L. W., 518
and client growth, 506 Sanders, P., 191, 192, 194
and core conditions of therapy, Sand-play therapy, 261
517–518 Satir, Virginia, 354
development of client-centered Sauer, E. M., 473
therapy by, 185, 186, 189 Saypol, E., 473
and emotion-focused therapy, Schechtman, Z., 400, 406
320, 331 Schema therapy, 227, 233
on emotions in psychotherapy, Schlegel, R. J., 33
147, 149 Schmid, P. F., 191
and empathy, 115–116, 120, Schneider, Kirk, 6, 295
121, 492 Schottelkorb, A. A., 395, 401, 402
existentialism’s influence on, 193 Schumann, B., 394, 397
and focusing-oriented–experiential Scott, L. N., 472
therapy, 258–259 Scott, T., 402
and human evolution, 190 Scuka, R. F., 363
incongruence theory of, 325 SDT (self-determination theory), 12, 191
and locus of control, 513–514 Secondary emotions, 357
and positive psychology, 191 Secord, P. F., 262
and positive regard, 497 Secure attachment, 472–473
on psychotherapy research, 405 Seeking of Noetic Goals test, 301
psychotherapy research by, 50, Seeman, Julius, 502
195, 457 Self-awareness, client, 93, 98–99
and qualitative research, 90–92 Self-concealment, 27–28
and relational depth, 202 Self-concept, 401–402
and relationship enhancement Self-criticism, 163
therapy, 355 Self-determination theory (SDT), 12, 191
and therapeutic presence, 489 Self-disclosure
therapist attitudes specified by, 65 and attachment style, 473
on therapist–client relationship, 425 client’s experience of, 430
and therapist factors, 421, 423 of emotions, 27
values of, 6 function of, 24
Rolling, E., 363 therapist congruence with, 499–500
Rollnick, S., 488 Self-empathy, 136
Rønnestad, M. H., 505 Self and self-concept
Rosner, R., 233 humanistic therapy’s influence on, 6
Routine monitoring, 66–68 importance of, 4–5
Rowe, M., 431 overview, 514–516
Rozmarin, E., 434–435 Self-soothing, 148, 157–158, 356–357
Rule of equalization, 221 Sells, D., 431
Rumination, 167 Sequential approach to therapy, 521
Rupture repair, 68, 425–426, 435–437. Shahar, B., 65, 335
See also Therapeutic alliance Shame, 164, 335
Rushanski-Rosenberg, R., 124 Sheehan, R., 360
Ryan, P., 227 Shelton, K., 101
Ryan, R. M., 191 Shen, Y., 398, 402, 406
Ryan, S. D., 363 Shimokawa, K., 67, 68, 505, 517, 518
index 551
Shirk, S., 404 Summers, L., 263
Shlien, J., 207 Supportive–expressive therapy, 286,
Shrout, P. E., 21 295, 302
Siegel, D., 404 Surace, F. I., 94
Silence in therapy, 85, 102–104 Sveško-Visentin, H., 231
Silverman, W. K., 403 Swan, K., 395, 400
Skillfulness, 22 Swann, W. B., Jr., 34
Skinner, B. F., 13 Swift, J. K., 471, 517
Smart, D. W., 67 Symbolization, 159, 168
Smith, E. W. L., 227 Symonds, D., 62, 434, 503
Smith, J. Z., 469, 508 Systematic evocative unfolding, 193
Smith, M. L., 196, 395
Smith, S. K., 363 Taft, Jessie, 186
Smith, T. B., 17 Tallman, K., 456, 457, 474, 507, 517
Smith, T. W., 488 Tausch, R., 195
Snyder, W. U., 195 Technical eclectic approach to therapy,
Social functioning, 33–34 521
Social support. See also Relational Tennessee Self-Concept Scale, 265
connection Terminal illness, 295–296
and emotional expression, 26 TF-CBT (trauma-focused cognitive–
importance of, 15–16 behavioral therapy), 403
Softening events, 366 Thematic analysis, 87
Somatic problems, 170 Theoretical integration approach to
Song, X., 469 therapy, 521
Soteria approach, 285 Therapeutic alliance
Sotskova, A., 120 capacity to repair, 298
Sousa, Alegria, 289 client’s role in, 458
Sousa, D., 287, 289, 293 conceptualizations of, 425–426
Spiegel, D., 295 definitions of, 62
Spinelli, Ernesto, 297 in emotion-focused therapy, 193,
Sprenkle, D., 360 322, 331–332
Standard view of person-centered empathy’s role in, 134–135
therapy, 259 and motivation, 468–469
Stanley, P. H., 515 overview, 502–504
Starling, M., 402 quantitative research on, 84
Steckley, P. L., 119 and therapeutic presence, 433
Sterner, L., 512 Therapeutic presence, 235, 489–492
Stevens, C., 228 Therapeutic Presence Inventory (TPI),
Stiles, W. B., 198 238, 491
Stoler, N., 498 Therapist–client relationship. See also
Stolorow, Robert, 224 Therapeutic alliance
Strauss, J. L., 435 client experience of, 517–518
Stringfellow, J., 228 concordance in, 124–125
Strümpfel, Goldman, 226–227 in existential therapies, 298–299
Strupp, H. H., 458 in Gestalt therapies, 221–222
Stuart, J., 494–495 importance of, 4, 14, 387–388
Stulmaker, H. L., 403 overview, 425–426, 434–439
Subjectivity of client, 4, 135, 285 qualitative research on, 93
Suicidality, 16–17 quantitative research on, 84
Suizzo, M. A., 34 and research outcome variance, 61–63
552 index

Therapist factors, 421–448 Tuen Ng, M. L., 230
case study with high-risk client, Tugade, M. M., 163
439–447 Twigg, E., 198
client–therapist relationship, Two-chair dialogue, 321
425–426, 434–439 Tyndall-Lind, A., 395, 402
in cognitive–behavioral therapy, 61
congruence and genuineness. See Uemura, T., 267
Congruence; Genuineness Uhlin, B., 469
early research on, 422–426 Unconditionality, 64, 495–497
empathy. See Empathy “Unfinished business” (Gestalt theory),
and outcomes, 428–429 325
overall effectiveness, 422–423, 427 University of Chicago Counseling
positive regard, 424, 431–439 Center, 195, 457
in relational depth, 202 University of Nottingham, 209
Therapist focusing, 270–271 University of Ohio, 195
Therapist investment, 522–524 Uysal, A., 31
Therapist–parent relationship, 359
Therapist presence, 6, 433–434, 489–492 Van Deurzen, E., 286, 293, 296–297
Therapist resonance, 121 VanFleet, R., 363
Thorne, B., 495 Van Huyssteen, C. G., 232
Timulak, L. Vollmer, B. M., 471
and emotion-focused therapy, 335 Vos, Joël, 307–309
and humanistic therapy processes Vulnerability, 335, 366, 503
and outcomes, 53, 64
and optimal practices of humanistic Wade, A. G., 487, 504, 508, 509, 518
psychotherapies, 518 Wagstaff, A. K., 460, 509
and philosophical principles of Wait-list control studies, 55
humanistic therapies, 387 Wakelin, K., 228
and qualitative research, 95, 98–99 Walfish, S., 66–67
Titus, G., 363 Walsh, R. A., 284
Tompkins, K. A., 517 Wampler, K. S., 363
Topham, G. L., 363 Wampold, B. E., 198, 201, 422, 432,
Toukmanian, S. G., 265 434, 455
TPI (Therapeutic Presence Inventory), Wang, C.-C., 64, 429, 500
238, 491 Waring, J., 228
Transparency, 498. See also Congruence Warwar, N., 512
Trauma. See also Posttraumatic stress Warwar, S. H., 153, 332, 333, 365
disorder Watson, J. C., 53, 234, 321, 387
complex, 156–158 and emotion-focused therapy,
emotion-focused therapy for, 334 330–332
relational, 152–153 and emotions in therapy, 29, 154
Trauma-focused cognitive–behavioral and empathy, 119–121, 424, 494
therapy (TF-CBT), 403 and humanistic therapy processes/
Traynor, W., 431 outcomes, 62, 63
Treatment resistance, 120, 469–470 and therapist factors, 428
Tri-Axial Coping Scale, 267 Weiss, B., 390–391
Truax, C. B., 50 Weissmark, M., 461, 514
Truax Relationship Questionnaire, 64 Weisz, J. R., 390–391
Tryon, G. S., 471–472 Welch, K., 395
Tsai, M., 395, 397 Westra, H. A., 471
index 553
Wexler, D. A., 320, 509 Working at Relational Depth in Counseling
Wheeler, Gordon, 219 and Psychotherapy (D. Mearns &
Wholeness (humanistic value), 322 M. Cooper), 501
Wiggins, S., 202, 299, 502 Wormith, J. S., 469, 506
Williams, P. G., 488 Worry, 167
Willutzki, U., 505 Worsley, R., 193
Wingrove, J., 236
Winograd, G., 471–472 Yalom, I. D., 160, 295–296, 523
Wisconsin Project, 191–192, 196 Yamaguchi, S., 261
Wiser, S., 503 Yerymenko, N., 153
Withdrawal emotions, 163 Yip, J. J., 28
Wittenborn, A. K., 364 York I study, 327
Wolff, M. C., 120 York II study, 328–329
Wong, P. T. P., 294 Yousefi, N., 229
Wood, A. M., 32–34
Woodin, E. M., 120 Zimring, F. M., 195
Working alliance, 117, 330. See also Zuccarini, D., 367
Therapeutic alliance Zuroff, D. C., 432, 434, 468
554 index

ABOUT THE EDITORS
David J. Cain, PhD, ABPP, CGP, is the author of Person-Centered Psycho

therapies (2010) and the therapist in the American Psychological Association
DVD “Person-Centered Therapy Over Time” (2010). He is the senior edi-
tor of Classics in the Person-Centered Approach (2002). A former colleague of
Carl Rogers, he is the founder of the Association for the Development of the
Person-Centered Approach and was the founder and editor of the Person-
Centered Review. He is a fellow in Clinical Psychology of the American Board
of Professional Psychology. Dr. Cain is a former president of the Society for
of Humanistic Psychology, initiated its annual, and is a recipient of its Carl
Rogers Award.
Kevin Keenan, PhD, received his MS and PhD in clinical psychology from
the University of Kentucky. He is a core faculty member of the Michigan
School of Professional Psychology. Dr. Keenan is on the executive board of
the American Psychological Association Division 32 (Society for Humanistic
Psychology [SHP]) and a fellow of the Michigan Psychological Association.
He is an associate editor for the Journal of Humanistic Psychology and coeditor
of SHP’s newsletter. Dr. Keenan has a private practice in Farmington Hills,
555
Michigan, and has special interests in recovery, spirituality, life-span develop-
ment, supervision, and relational depth psychotherapy.
Shawn Rubin, PsyD, was trained by Clark Moustakas, PhD, and carries
on the work of his mentor by presenting and training internationally on human-
istic approaches to play therapy, parent guidance and support, the heuristic
research method, clinical supervision, and the experiential teaching and train-
ing of graduate students across the helping professions. He is chair of the
School of Clinical Psychology at Saybrook University and director of both
the PhD and PsyD programs in clinical psychology. Dr. Rubin serves as editor
in chief of the Journal of Humanistic Psychology and board member of American
Psychological Association Division 32 (Society for Humanistic Psychology).
556 about the editors

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Humanistic

American Psychological Association • Washington, DC

Typeset in Goudy by Circle Graphics, Inc., Columbia, MD

Printer: Edwards Brothers, Inc., Lillington, NC

Library of Congress Cataloging-in-Publication Data

Humanistic psychotherapies : handbook of research and practice / David J. Cain,

British Library Cataloguing-in-Publication Data

Printed in the United States of America

I. Historical and Conceptual Foundations............................................... 9

II. Overviews of Research....................................................................... 47

III. Major Therapeutic Approaches..................................................... 183

IV. Therapeutic Modalities................................................................... 351

viii contents

VI. Analysis and Synthesis................................................................... 483

xii contributors

xiv preface

I, David J. Cain, acknowledge the many people who have inspired me

I, Kevin Keenan, acknowledge Billie Ables, whose kind critique of my

I, Shawn Rubin, acknowledge the incredible efforts of the coeditors and

xviii acknowledgments

DEFINING HUMANISTIC PSYCHOTHERAPIES

4 cain, keenan, and rubin

RESEARCH SUPPORT FOR HUMANISTIC PSYCHOTHERAPIES

In the past few decades, the research on humanistic psychotherapies has

6 cain, keenan, and rubin

OVERVIEW OF THIS BOOK

This second edition of Humanistic Psychotherapies gives us strong reasons

8 cain, keenan, and rubin

More than 60 years from its origin in humanistic psychology, human-

12 cooper and joseph

RELATIONAL CONNECTION AND SUPPORT

A core assumption across the humanistic psychotherapies is that the

Interpersonal Connection and Mental Well-Being and Health

To what extent, then, do theory and research from the psychological

14 cooper and joseph

Mental Health Difficulties

16 cooper and joseph

From Research to Practice

18 cooper and joseph

With respect to interpersonal relating, a second line of psychological

20 cooper and joseph

From Research to Practice

22 cooper and joseph

24 cooper and joseph

VALUE OF EMOTIONAL EXPRESSION AND PROCESSING

“One of the most distinguishing features of humanistic therapies,” wrote

26 cooper and joseph

The opposite of self-disclosure is self-concealment, defined as the “pre-

Why, and Under What Conditions, Is Emotional Expression Beneficial?

So how might emotional expression be of benefit to people, and what

Reduction in Physiological Strain

28 cooper and joseph

Allowing Thoughts to be Challenged

From Research to Practice

From the psychological evidence, there are good grounds to believe

30 cooper and joseph

A third, interlinked construct that cuts across theories of humanistic

Psychometric Scale Development

First, the Authenticity Scale, developed by Wood, Linley, Maltby,

Well-Being and Mental Health