Humanistic Therapies Theoretical Basis

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As with constructivist therapies, humanistic therapies encompass a range of different approaches. However, as Elliott (2001, p. 38) indicates, they 'share a set of values, including grounding in immediate, lived human experiences; fostering of agency and self-determination; prizing of differences within and between people; relationships based on authentic presence; and pursuit of wholeness and growth throughout the life cycle.'

The first major humanistic therapies to be developed were Carl Rogers' (1961) client-centred (now usually referred to as person-centred) therapy and Fritz Perls' Gestalt therapy (Perls etal., 1974). In the former approach, the person is seen as having an inherent tendency to actualise his or her potential. This tendency is manifested in the fully functioning person, who is characterised by openness to experience. However, the process is likely to be blocked, with consequent estrangement of the individual from his or her true self if the person is subjected to 'conditions of worth' from others who, for example, offer their love only if the person acts in a certain way. In such a case, the person may introject the attitudes of the other people concerned and develop a negative self-concept, which will be preserved by mechanisms of perceptual distortion and denial. His or her primary concern is likely to be with obtaining the approval of others.

Gestalt therapy shares with person-centred therapy a concern with awareness of the self, of the environment, and of the person's internal processes. Imbalances in or between these areas are experienced as needs, the person becoming aware of a 'Gestalt' in which their dominant need is differentiated as a figure against the ground of their total experiencing. The tension associated with the imbalance leads the person to satisfy the need, thereby destroying the Gestalt, which is replaced by another concerned with the person's next most dominant need. This ongoing, homeostatic process, involving the maintenance of the person's equilibrium, characterises healthy functioning. Psychological problems occur when this process is interrupted, perhaps by individuals being constantly prevented from expressing or meeting their needs with a consequent build-up of incomplete Gestalts, or unfinished business. This is likely to be associated with persistent disturbances at the 'contact boundary' between self and environment. Such disturbances include introjection of whole parts of the environment, such as attitudes of others; projection of disowned aspects of the self onto others or the environment; retroflection, in which energy is turned against the self; confluence, in which the self-environment boundary is unclear; and deflection of the person from contact with the environment. In general, there is an attempt to change the self or the environment to fit the person's image of them.

Transactional analysis (Berne, 1968) regards psychological disturbance as resulting from the person's autonomy having been interfered with by parents or other significant figures who have not adopted the respectful position of 'I'm OK - You're OK'. Decisions made by the person in childhood are viewed as determining the scripts that are followed, sometimes self-destructively, throughout life, essentially in an attempt to obtain love. A tripartite model of the person, consisting of Parent, Adult, and Child ego states, is employed, with pathology being reflected in one ego state being contaminated by another or there being insufficient energy to cathect, or invest in, one or more of the ego states. In general, therapy aims to enable the client to cathect their Adult ego state. Transactions between people are viewed in terms of the ego states that are involved, the patterns of 'strokes' that they exchange and the 'games' that they play.

Also within the broad humanistic tradition are existential approaches to therapy (Van Deurzen-Smith, 1988), which have their roots in existential philosophy and phenomenology. A primary concern in these approaches is the individual's confrontation with the 'givens of existence', namely the inevitability of death; the freedom that accompanies individuals' responsibility for their choices and actions; the existential isolation of each individual; and the essential meaninglessness of the universe (Yalom, 1980). The person who is able to face these givens can live an authentic existence (Heidegger, 1962), true to their experience of the world. However, attempts to avoid the angst, or existential anxiety, which accompanies the awareness of one's essential nothingness (Kierkegaard, 1954) can lead a person into a life of inauthenticity or bad faith (Sartre, 1951), in which, for example, their actions are determined by conformity with values other than their own. Another path to psychological disturbance, but in this case to a likely diagnostic label of psychosis, is an authenticity untrammelled by any acknowledgement of external reality.

Distinguishing Features of Therapy

Humanistic therapies aim to promote the client's self-awareness and in most cases also regard the facilitation of the client's personal growth as a therapeutic goal. They generally consider the therapeutic relationship to be of particular importance in this process. Although these features might appear to be shared with psychodynamic therapy, the focus in humanistic therapies is more on the here and now than on the past. The authenticity of the client-therapist relationship is considered of primary importance rather than its transferen-tial aspects. This relationship is also more democratic than in many other forms of therapy. A further characteristic of some humanistic approaches, deriving from their holistic view of the person, is that, as well as more conventional areas of therapeutic focus, they may use body-oriented approaches or be concerned with transpersonal issues (Rowan, 1993).

Several studies have provided evidence of the distinctive features of humanistic therapies and of particular approaches within this tradition (Greenberg, Elliott & Lietaer, 1994).

Therapeutic Practice

The humanistic approaches that have placed greatest emphasis on the therapeutic relationship are person-centred and existential therapy. Rogers (1957), presenting the former approach, regarded as necessary and sufficient conditions for therapeutic change a relationship in which the therapist is perceived by the client as congruent (genuine), accepting, and empathic. In Rogers' view, the client who is provided with these 'core conditions', rather than the previously experienced conditions of worth, will naturally grow. The original non-directive Rogerian approach, in which the therapist acts as a reflective screen, has been replaced by a rather more task-oriented therapeutic style in some later variants of person-centred therapy. Wexler (1974), taking a cognitive perspective, views the therapist as a surrogate information processor whose accurate empathy allows an organisation of meaning which is more accurate than that of the client. Rice (1974) has developed, and manualised, a method of evocative unfolding of problematic reactions, in which an incident is re-evoked in therapy and more completely reprocessed. Gendlin (1996) uses a focusing method to allow the client to develop a 'felt sense' of experience, which is both psychic and bodily.

In existential psychotherapy, the focus is on the personal encounter, in an 'I-Thou' relationship (Buber, 1958), between therapist and client (Spinelli, 1994). In this relationship, the therapist helps the client to explore the meaning of his or her experiences by seeking clarification of, and occasionally challenging, the client's statements.

Various other humanistic therapies are characterised by a more active therapeutic style and a greater use of techniques. The first such approach was Moreno's (1964) Psychodrama, in which enactment is used to provide the client, or protagonist, with a cathartic re-experiencing of conflict situations. In the enactment, therapeutic aides or other members of a therapy group act as 'auxiliary egos' who play counter roles to the protagonist and may occasionally reverse roles with him or her; act as a 'double' by standing by, and perhaps speaking for and emphasising the feelings of, the protagonist; or 'mirror' the protagonist by re-enacting a scene that he or she has just enacted.

Gestalt therapy is also relatively active and directive, encouraging the client to engage in experiments to promote experiential learning. The Gestalt therapist may attempt to facilitate greater awareness by changing the client's use of language. This may, for example, involve the client being asked to make statements rather than to ask questions, to personalise these statements by using the first person pronoun when appropriate, and also to take greater responsibility by using 'won't' rather than 'can't'. The therapist will also attend to the client's non-verbal communication, helping the client to become more aware of its meaning by such means as asking him or her to exaggerate particular gestures. In 'two-chair dialogue' the client is asked to move backwards and forwards between chairs representing split and conflicting aspects of the self; while in 'empty chair dialogue' the client is encouraged to express feelings to an imagined significant other in an empty chair in an attempt to resolve unfinished business with this person. Chairs may also be used in transactional analysis, clients carrying out a dialogue between their three ego states by moving backwards and forwards between chairs representing these states.

The integration of Gestalt techniques and other active interventions into an essentially person-centred therapeutic approach has led to the development of process-experiential therapy (Elliott & Greenberg, 1995; Greenberg, Rice & Elliott, 1993). As well as its use with individual clients, this method has been adapted for work with couples (Johnson & Greenberg, 1985a). There has also been extensive use of all of the humanistic therapies in the group setting (Lietaer, Rombauts & Van Balen, 1990; Yalom, 1970).

Training

Consistently with their emphasis on the quality of the therapeutic relationship, humanistic therapies generally regard the personal development of the therapist as being at least as important as training in particular therapeutic approaches. The early training courses arising from the person-centred tradition included teaching in the provision of Rogerian therapeutic conditions (Truax & Carkhuff, 1967). As well as didactic components, training incorporated a quasi-group therapy experience in which the focus was on trainees' difficulties in their therapeutic role. Although a considerable amount of research was conducted on this training, the adequacy of the methods used in this research has been questioned (Matarazzo & Patterson, 1986).

Humanistic therapy courses now generally require their trainees to undergo therapy of the type that they are going to offer. They may also foster group interaction and support and an intense focus on subjective experience by such means as the inclusion of residential components. In addition, they may incorporate artistic, spiritual, and physical activities designed to promote all aspects of the personal growth of the therapist (Pierson & Sharp, 2001). The length of training is generally at least three to four years.

Supervision

Humanistic therapists are required to undergo regular supervision and, in most humanistic approaches, the supervisor-supervisee relationship, like that between therapist and client, is regarded as at least as important as more didactic aspects of the process. As Truax & Carkhuff (1967, p. 242) described, 'the supervisor himself provides high levels of therapeutic conditions'. Discussion of difficulties that have arisen in therapy will also focus at least as much on the therapist's role in these difficulties as on that of the client.

Evidence of Effectiveness

Many humanistic therapists, like several of those from the constructivist school, have been highly critical of published criteria for 'empirically validated treatments', considering that these may lead their therapies to be disenfranchised and 'empirically violated' (Bohart, O'Hara & Leitner, 1998). For example, the view has been taken that, to quote the Association of Humanistic Psychology Practitioners, 'Quantitative research methods are of doubtful value in relation to understanding people and their relationships.' Research on the humanistic therapies has therefore tended to rely heavily on the use of qualitative methods, and to give greater emphasis to investigation of the therapeutic process (Greenberg & Pinsof, 1986; Toukmanian & Rennie, 1992) than to that of outcome.

There is, however, a substantial research literature on the effectiveness of some humanistic therapies. Carl Rogers himself was very much involved in the earliest studies in this area, which provided evidence of the effectiveness of the person-centred approach in, for example, enhancing self-acceptance and adjustment (Cartwright, 1957; Rogers & Dymond, 1954). Several subsequent studies have used person-centred therapy as a placebo control in comparison with cognitive-behavioural and other therapies. Although these have found cognitive-behavioural therapies to be superior, there are indications that this difference between therapies disappears when allowance is made for researcher allegiance (Elliott, 2001). In addition, some more recent studies (Kay et al., 2000; Tarrier et al, 2000) have not supported the superiority of cognitive-behavioural over person-centered therapies. The effect of the therapeutic relationship on outcome in person-centred and other therapies has also received considerable research attention. These studies have supported the importance of the therapeutic alliance, and while evidence concerning the facilitative effect of Roge-rian therapeutic conditions has been conflicting (Greenberg, Elliott & Lietaer, 1994), the therapist's empathic understanding and acceptance of the client have generally been related to favourable outcome, albeit to different degrees with different types of client (Bozarth, Zimring & Tausch, 2002; Sachse & Elliott, 2002). There has also been a certain amount of research on techniques that may be used in person-centred therapy, although in several cases these have been analogue studies. For example, successful evocative unfolding of problematic reactions has been related to reduction in anxiety (Lowenstein, 1985), and there is evidence that sessions in which this technique is used are of greater value than less task-oriented sessions (Rice & Saperia, 1984; Wiseman & Rice, 1989). Therapist 'processing proposals' in person-centred therapy have been found to be effective in influencing clients' information processing, whereas therapist facilitative conditions have not been found to be sufficient in this regard (Sachse, 1990; Sachse & Elliott, 2002). Greenberg, Elliott & Lietaer (1994) have reviewed studies of focusing that have found this to be associated with self-acceptance and reduction in internal disorganisation, with reduction in depression and improvement in body image in cancer patients and with greater improvement at follow-up in a weight-loss programme than in clients receiving cognitive-behavioural treatment.

Although the outcome of Gestalt therapy, at least in its pure form, has received rather less research attention, there is some evidence that this approach is as effective as behavioural and cognitive therapies (Beutler et al., 1991; Cross, Sheehan & Khan, 1982; Strumpfel & Goldman, 2002). There has also been exploration of the effectiveness of particular techniques derived from Gestalt therapy. Two-chair dialogue for conflict splits has been found to be more effective in some respects than empathic reflection and focusing (Greenberg & Dompierre, 1981; Greenberg & Higgins, 1980; Greenberg & Rice, 1981) and to result in greater reduction in indecision in clients with decisional conflicts than did behavioural problem solving (Clarke & Greenberg, 1986). Further studies have investigated the mechanism of change produced by the two-chair technique (Greenberg, 1984). Empty-chair dialogue for unfinished business has also been examined by Paivio and Greenberg (1995), who found it to be more effective than a psycho-educational group both in terms of symptom reduction and resolution of unfinished business. More favourable treatment outcome occurred in those clients who expressed previously unmet needs and showed changes in their perception of the significant other (Greenberg & Malcolm, 2002). The use of this technique, particularly to facilitate expression of anger, in clients presenting with depression and chronic pain has also been found to lead to improvements in both these areas, although education groups were equally effective in reducing pain (Beutler et al., 1988, 1991).

A related body of research has investigated the outcome of other forms of process-experiential therapy. This approach has been found to produce effects equivalent to those of cognitive and dynamic therapies with depressed clients (Elliott et al., 1990; Greenberg & Watson, 1998), and there are indications of its effectiveness with survivors of abuse (Elliott & Greenberg, 2002). Marital process-experiential therapy has also been found to be very effective and more so than behavioural problem-solving treatment (Dandeneau & Johnson, 1994; Gordon Walker et al., 1996; Johnson & Greenberg, 1985a, 1985b).

There has also been some outcome research on humanistic group therapy (Page et al., 2002). For example, studies of psychodrama groups have demonstrated the value of 'doubling' in increasing group members' verbal output (Goldstein, 1967,1971). An investigation of encounter groups by Lieberman et al. (1973) indicated that, although such groups can have powerful effects, these can result not only in positive change but also in 'casualties', therapeutic style appearing to be a major factor in determining outcome. Anderson (1978) found Rogerian and Gestalt groups to be effective in reducing depression and anxiety but no more so than a leaderless group. There have also been indications of the effectiveness of existentially oriented group therapy in populations ranging from drug users (Page, Weiss & Lietaer, 2002) to cancer patients (Van der Pompe et al., 1997).

Although an early meta-analysis suggested less favourable outcomes for humanistic therapies (Smith, Glass & Miller, 1980), more recent meta-analyses have indicated large effect sizes for pre- to post-treatment change in these therapies, particularly with relationship problems, anxiety and depressive disorders and trauma, with treatment gains generally being maintained at follow-up (Elliott, 1996, 2001, 2002; Elliott, Greenberg & Lietaer, 2004; Greenberg, Elliott & Lietaer, 1994). There is also evidence of such therapies being 'possibly efficacious' for people diagnosed with anger-related problems, schizophrenia, severe personality disorders and physical health problems. In comparative outcome studies, these effect sizes are generally equivalent to those in the other therapies studied, but considerably greater than those in untreated controls. There are also indications of greater effect sizes for Gestalt and process-experiential than for non-directive humanistic therapies.

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