From Client-Centered Psychotherapy to Clarification-Oriented Psychotherapy

Transkript

1 Rainer Sachse From Client-Centered Psychotherapy to Clarification-Oriented Psychotherapy Abstract The following article critically discusses the concept of classic Client-Centered Psychotherapy and draws conclusions from the available outcome and process research that call for conceptual changes to the therapy. A change of paradigms from a primarily relationship-oriented psychotherapy to a primarily clarification-oriented psychotherapy is suggested. 1. Introduction Today Client-Centered Psychotherapy (CCT) is no longer a uniform psychotherapy (see Sachse, 1999): It takes various forms ranging from non-directive approaches (see Biermann-Ratjen et al., 1995; Mearns & Thorne, 1996; Schmid, 2002) via processexperiential psychotherapy (see Greenberg, 1984; Greenberg et al., 1993; Rice & Greenberg, 1974, 1984a, 1984b, 1984c, 1990) to goal-directed psychotherapy (see Sachse, 1992, 1996, 2003). The objective of this study is to show that CCT has developed significantly in the last few years and that, based on the results of process research, a fundamental change of paradigms is about to take place, which will lead to a new form of CCT that I would like to call Clarification-Oriented Psychotherapy. 2. Empirical Evidence and Conclusions I would like to begin my exposition with some résumés of empirical evidence. On the basis of these résumés I wish to illustrate the current status of empirically based research, focusing on the results of process research. And I would like to make clear from what scientifically supported knowledge base we can - and must - start today, if we want to practice scientifically based CCT. I do not wish to deal with the research itself; that would mean going into too much detail. Rather, I would like to present the conclusions that can be drawn from the available research. 1

2 I only wish to cite here the studies on which my conclusions are based, so that any audience member can verify my conclusions. The main studies are: Orlinsky & Howard, 1986; Orlinsky, Grawe & Parks, 1994; Grawe, Caspar & Ambühl, 1990a, 1990b; Grawe, Donati & Bernauer, 1994; Greenberg, Elliott & Lietaer, 1994; Elliott, 1996, 2002; Sachse & Elliott, 2002; Sachse, 1992, 1999; Sachse & Takens, First of all, I would like to draw some conclusions from the outcome research. These conclusions are also essential in regard to the consequences they have for the concepts of the CCT process. The conclusions that I consider to be relevant are the following: 1. In effectiveness studies, traditional client-centered (Rogerian-style) psychotherapy has without exception - proved only moderately effective. The average effect sizes are about 1.3 (Grawe et al., 1994). Classic CCT assists clients only moderately in making constructive changes. But changes in clients are necessary, brought about by processes of change initiated through the therapeutic proposals made by the therapist. If the therapeutic results are only moderate, then, logically, the processes of change encouraged by the therapist were only moderate, too. This reason alone is sufficient to think about how therapeutic processes and interventions should be conceived. Even if the therapies efficiency would be clearly higher, one still could not conclude, the therapy being optimal and should not be further improved: Each therapy has to be further improved, because it is the overall central goal to provide clients the best available supply. 2. Classic CCT has in general proved less effective than Cognitive Therapy. This, too, shows that Cognitive Therapy produces more effective processes in clients than CCT does (Grawe, 1992; Grawe et al., 1994). 3. The effective spectrum of classic CCT is significantly narrower than that of interactional behavior therapy (Grawe et al., 1990a, 1990b). The processes of interactional behavior therapy produce far more changes than can be achieved with classic CCT (Grawe, 1988, 1992; Grawe et al., 1990a, 1990b, 1994): So it is possible, in principle, to encourage a very large number of changes. In this respect, CCT is, however, far from being optimal. Obviously, CCT fails to optimally exploit the potential of the therapeutic process. It is imperative that this evidently dysfunctional restriction be overcome. 4. Thus classic CCT is by no means a highly effective form of therapy; it is far from being ideal (Bastine, 1982; Bommert, 1987; Minsel & Langer, 1974; Tomlinson & Hart, 1962). 2

3 Therefore - if clients are to be given effective help - CCT cannot be preserved as it is. Preserving the therapy in its classic form is not empirically justified in any way. It must rather be developed further. 5. Offering clients classic person-centered therapy means offering them a suboptimal method. The interventions produced, in particular, do not have the quality to initiate optimal changes. Offering that method is not client-centered. It is, at best, ideology-centered or therapistcentered. For this reason alone, it is absolutely essential that CCT be developed further. 6. More directive forms, such as process-experiential psychotherapy, show substantially higher effect sizes - comparable to those of Cognitive Therapy. But then, they also have totally different concepts of the therapeutic process, which appears to me to be the most important aspect: They use different and more extensive interventions and therapeutic strategies (Elliott, 1996; Greenberg, Rice & Elliott, 1993; Greenberg, Elliott & Lietaer, 1994). 7. A further development in theoretical and methodical terms is what I call Clarification- Oriented Psychotherapy. That therapy is process-directive and process-oriented. Clarification-oriented psychotherapy shows effect sizes of 2.3 (Sachse, 1991c, 1994e, 1995c, 1997a, 1998c). It is thus as effective as Cognitive Therapy. This shows that CCT can effectively be developed further and that it must in fact be developed further. 8. But further development means change. If the CCT system changes, it will no longer remain a pure Rogerian system: It will develop itself away from Rogers, but still will base on the foundations of the Rogerian theory, similarly to a developing personality still basing on its biography. But, someone who is 50 years old has different behavioral skills, motives and different knowledge than someone who is 5 years old; that s the way how a psychotherapy-system should be considered. If we want to develop the therapy further, we must change the classic form of Client-Centered Therapy. 9. According to studies, the relationship characteristics or relationship variables empathy, acceptance and congruence correlate on average 0.20 with the therapy success. This means: Relationship characteristics have only a marginal impact on the success of the therapy. Thus, relationship structuring by the therapist in general practically nontherapy-relevant (Orlinsky & Howard, 1986; Orlinsky, Grawe & Parks, 1994; Truax & Mitchell, 1971). 3

4 So considering CCT as relationship therapy is not empirically justified. That is sheer, unproven ideology. Thus relationship is not the essential effective variable of CCT. Relationship structuring by the therapist is probably an important, albeit insufficient prerequisite for effective therapy (Sachse, 1993). Relationship is a prerequisite for further constructive work; without it, constructive work is not possible. But the therapeutic proposal must be much more than an offer of relationship (Sachse, 1992a). And this means that the therapeutic process in CCT can only in part be seen as an offer of relationship. There is no justification for interpreting all that happens in the therapeutic process as a relationship or a relationship-structuring process. It is obvious that also other, highly relevant things happen, or should happen, during the therapeutic process that give the client optimum support in his process of change (Sachse, 1992a). 10. In contrast, the quality of the clarification process correlates more than 0.60 with the therapy success. In CCT, the significant therapeutic effects are produced by clarification processes (Sachse, 1992a). Also other studies show, that clarification processes are the actual relevant processes in therapy (Bullmann, 2003). Thus CCT should better be developed as Clarification-Oriented Psychotherapy rather than Relationship-Oriented Psychotherapy. Therefore, a large part of the therapeutic process should be conceptualized as a clarification process: a process, in which clients represent, restructure, and integrate relevant cognitive and/or affective schemata. For this reason it is important to look more closely at the role that clarification processes play in client-centered therapy. I would like to do so based on conclusions drawn from a number of process studies. The conclusions are: 1. Through their interventions, therapists have a very strong directive effect on their clients clarification processes. Whether they want to or not, they act directively, they influence the client processes. Thus there is no such thing as non-directive therapist behavior (Sachse, 1984, 1986c, 1988c, 1990a, 1990b, 1990c, 1991a, 1991b, 1992a; Sachse & Takens, 2003; Takens, 2001; Truax & Mitchell, 1971). Empirically, the concept of non-directive psychotherapy is plainly and simply untenable. Consequently, the concept of non-directivity should be eliminated from the process concepts of CCT (Bastine, 1982; Bommert, 1987; Greenberg & Pinsof, 1986). 4

5 2. Clients let themselves guide extensively in their clarification process by therapists. This means they let themselves influence by therapists, they are basically open to therapeutic intervention (Sachse, 1990a, 1991a, 1992a; Sachse & Maus, 1987, 1991). So clients do want therapists to direct their process, which means that directive therapist behavior is highly client-centered. A vital element of the therapeutic process is thus process-directive intervention, intervention that deliberately steers the clients clarification processes (Greenberg & Pinsof, 1986; Greenberg, Rice & Elliott, 1993). 3. To deepen the clarification process, clients require extensive intervention from the therapist. They virtually never deepen the process on their own. To be able to start a constructive clarification process, clients require guidance from the therapist. A selfinitiated deepening of the clarification process practically never happens. This means: Clients show no actualizing tendency in their own clarification processes (Sachse, 1990a, 1990b, 1990c, 1991a, 1991b, 1991c, 1992a, 1994c, 1995a, 1995b, 1995c, 1997a, 1997b; Sachse & Takens, 2003). Should there be such a thing as an actualizing tendency - which I doubt there is - it certainly does not occur in the therapeutic process. 4. Clients get very easily distracted from the clarification process. They are highly liable to accept flattening processing proposals; they are thus not immune to influences from the therapist (Sachse, 1992a; Sachse & Maus, 1987, 1991). So therapists can act grossly untherapeutically, especially if they are not experts, but just good people. 5. For clients, the deepening process is difficult and challenging (Sachse, 1992a, 1992b; Sachse & Maus, 1987, 1991). Clients need to focus fully on that process, in which the therapist-client relationship evidently becomes a background variable, it must be there, but it must never get into the focus of the therapeutic work (Sachse, 1986a, 1986b, 1988a, 1996a, 1996b, 1999b, 2003). 6. Clients also require constant directive support from the therapist in maintaining a deepening process; without that support, the client s clarification process will flatten. So therapists need to know exactly when and how they must and can stimulate client clarification processes (Sachse 1992a; Sachse & Takens, 2003). 7. A therapist must encourage a client s explication process in a specific manner in order to initiate effective clarification. This means, the therapist must make sure that the process develops slowly, step by step, and - if possible - without omitting any explication stage. 5

6 So the therapist s behavior can be highly constructive - or highly destructive (Sachse & Takens, 2003; Takens, 2001). To be able to act constructively, therapists need to have a high level of therapeutic knowhow and they must at all times be fully aware of where the clients are in their process. 8. So the therapist has a great effect on the clients clarification processes. He should thus be an expert on the process, who steers the processes deliberately and constructively. He has great process responsibility in the therapeutic process. He is thus far more than a provider of room for growth or relationship: Through his active behavior, he significantly determines the quality of the client processes (Becker & Sachse, 1997; Gäßler, 1994; Gäßler & Sachse, 1992a, 1992b; Sachse, 1992b, 1992e, 1992g). He deliberately influences the client clarification process, which he must do, because the client needs that support. Otherwise, he would leave the client alone. Probably the most significant conceptual change required to the CCT process results from the conclusion, drawn from the available evidence, that therapists practicing CCT need to be experts - experts have specific knowledge, perform process analysis, make therapeutic decisions, and produce interventions (Becker & Sachse, 1997; Gäßler, 1994; Gäßler & Sachse, 1992a, 1992b; Sachse, 1992b, 1992e, 1992g). And it is probably this change that is the hardest to accept for the proponents of classic CCT. But I believe that there is no way for us to get around this conclusion, unless we persistently ignore all empirical data. The assumption that a therapist should be an expert, however, has far-reaching consequences and calls for further conceptual changes. 9. The better the therapist understands the client, the stronger his influence will be on the client s clarification process (Sachse, 1990b, 1991c, 1992a; Sachse & Takens, 2003). Clear therapeutic understanding is the necessary prerequisite for the therapist being able to make his client constructive proposals in the first place. 10. Understanding the client, however, is not enough. Not only must the therapist understand what the client means, but he must also make clear to the client how the client must now work on what question, i.e. he must provide constructive encouragement, which means the therapist must make processing proposals to the client (Sachse, 1990a, 1990b, 1990c, 1992a; Sachse & Takens, 2003). 11. Therapeutic intervention can be implemented more easily and used more constructively by clients, the more effectively the therapist focuses his intervention on the core, i.e. on the central issue that the client is concerned with (Sachse, 1992a). 6

7 12. The therapist is able to constructively steer the client s clarification process only if he understands what the client means and relates as closely as possible to the client (Sachse, 1992a). For this purpose, too, a therapist must have expert knowledge and he must form a model of the client: He must not only understand what a client says, he must understand what a client means, and he must understand the client s schemata, i.e. his internal reference system, i.e. he must form a client model. 13. Therapeutic intervention will in particular have a constructive effect on the client clarification process, if the intervention is short; contains only one instruction at a time; is clear and comprehensible; expresses directly and explicitly rather than indirectly and implicitly - what the therapist means (Sachse, 1993a). 14. Therefore, the therapist should be an expert. He needs to be highly competent to understand what the client means, so that he can constructively direct the client by producing deliberate, effective interventions. So the therapist must have knowledge and empathy, he must do the right thing at the right time and he must form a model of the client and his process. 15. Clients come into therapy with different starting conditions: different problems, different motives, different levels of intra-personal exploration etc. (Sachse, 1992c, 1993c, 1997a, 2000a, 2001a). 16. If clients respond poorly to clarification-oriented intervention from the therapist, it is necessary to use other therapeutic means to foster the client, such as processing the processing or complementary relationship structuring. Such interventions enhance the clients responsiveness to clarification-oriented intervention. 17. Clients with psychosomatic intestinal diseases (morbus crohn and colitis ulcerosa) show poorer acceptance of deepening processing proposals and a higher level of avoidance than axis-i-clients do. In the case of psychosomatic clients, an effective therapeutic approach consists in adopting a more process-directive attitude and producing a high level of specific interventions; classic CCT approaches are in fact absolutely ineffective (Sachse, 1990b, 1991e, 1995a, 1995b, 1995c, 1997a, 1997b, 1998c, 1999c; Sachse & Atrops, 1991; Sachse & Rudolph, 1992a, 1992b). 7

8 18. For this reason, therapists must differentially adjust to the clients starting conditions; they must adopt a disorder-specific approach and must certainly not make the same proposal to all clients. Thus CCT urgently needs disorder-specific concepts (Sachse, 2000d, 2001b; Swildens, 1989). This is probably the second most important conclusion that must be drawn from the empirical data: Therapists must act in a disorder-specific fashion. To do this, they must first identify the disorder - they must make a diagnosis. To be able to do this, they must have disorder-specific knowledge. And they must act in a manner that takes account of the particular disorder, which means that their behavior must be target-oriented, based on knowledge and client processes. So they do more than making an offer of relationship and they do not by any means offer all clients the same concept. To meet all these requirements, therapists need to be experts. From this follows that a disorder-specific approach is impossible for a therapist to adopt without an expert status. But disorder-specific behavior goes far beyond the therapeutic concept of classic CCT. 19. How rapidly a therapist can deepen a client s clarification process and how effectively he can foster the client thus depends also on the client s characteristics (Sachse & Takens, 2003). For this reason, therapists also need to have knowledge about the clients disorders and the starting conditions resulting therefrom and about what therapeutic approaches the clients will respond to. 20. The depth of the clarification process increases continuously as the therapy progresses (Frohburg & Sachse, 1992; Sachse & Takens, 2003). The client achieves the deepest explication level when he is about halfway through the therapy. Towards the end of the therapy, the depth will slightly decline again. 21. Even in the course of a single session, the explication levels will slowly increase. Clients do not immediately begin the clarification process, but require a starting phase (Sachse & Maus, 1991; Sachse & Takens, 2003; Takens, 2001). 22. Experienced therapists influence client processes more rigorously and make more proposals to deepen the processing than inexperienced therapists do. It is for this reason that clients of experienced therapists show deeper clarification processes than clients of inexperienced therapists (Frohburg & Sachse, 1992; Sachse & Takens, 2003). 8

9 3. Developmental Lines of Clarification-Oriented Psychotherapy Resulting from Empirical Evidence I would now like to derive a number of proposals from the empirical evidence for the further development of CCT, notably proposals that relate to the process concepts of CCT. These proposals lead to a change of the fundamental paradigm: While the therapy continues to be based on the fundamental variables empathy, acceptance and congruence thus remaining a client-centered therapy its core is crystallizing into a clarification-oriented concept - which has far-reaching consequences for the concept of the therapy. 1. From CCT to Clarification-Oriented Psychotherapy It is clear that the basic variables empathy, acceptance and congruence form an indispensable foundation for building a trustful therapeutic alliance (Orlinsky, Grawe & Parks, 1994; Sachse, 1987). These therapeutic conditions must continue to form the basis of any type of CCT, but they must be just the basis (Bommert, 1987; Finke, 1999). And it is clear that a good therapist-client relationship constitutes an indispensable basis for good clarification-oriented work (Sachse, 1992a). The therapist-client relationship is an essential prerequisite for all therapeutic clarification processes: Without a trustful relationship, there can be no clarification processes. And it is further clear that relationship structuring as such is an important therapeutic catalyst for some clients (Heinerth, 1982). In fact, a therapeutic relationship alone is sufficient to trigger constructive changes in some clients. But such clients are certainly not the majority. However, a relationship offer is, in general, far from being enough. For this reason, CCT should not be centrally defined as a relationship therapy. Rather, the emphasis of the therapeutic work should be on clarification / explication processes. Clients should be specifically aided in representing problem-relevant cognitive and affective schemata, in developing an awareness of these schemata and in making these schemata accessible to further therapeutic processes. This orientation toward clarification should in my view be the central element and central expertise of CCT. Clarification orientation is highly client-centered, because it helps the clients in a highly effective manner and because clients expect that sort of help from therapists (Becker & Sachse, 1997; Sachse, 1994b). Moreover, the clarification processes that CCT offers the clients are unique in psychotherapy. Neither behavior therapy, nor cognitive therapy, nor psychoanalysis offers this form of structured therapeutic process (see Sachse, 1995d, 1998a; Sachse & Takens, 2003). 9

10 2. Empathic understanding: From entering a person to reconstruction Empathic understanding, as the empirical evidence shows, is a necessary prerequisite for a therapist to understand the client and for his ability to facilitate the client clarification process (Sachse, 1992a). However, the classic conception of emphatic understanding is not sufficient. A therapist cannot enter the client directly, unless he is telepathic, which only few therapists are. On a psychological level, understanding is rather a highly complex reconstruction process, which therapists perform based on their knowledge and their client models (see Engelkamp, 1984, 1994; Herrmann, 1982, 1984, 1985; Herrmann & Grabowski, 1994; Hörmann, 1976a, 1976b; Sachse, 1988b, 1989, 1991d, 1992d, 1993b, 1996b, 2000b). The concept of phenomenological understanding is absolutely untenable from a psychological point of view. This concept is a philosophical concept, but by no means a psychological concept. It leads to a highly naïve and false understanding of the relevant processes: The assumption that behavioral processes are phenomenological processes is in stark contrast to all the empirical evidence relating to psychology of language (see Langenmayr, 1997). This concept should therefore be definitely abandoned. The processes of understanding should rather be approached from a psychology-of-language perspective. Here it must be made clear that understanding is a process that is always aided by a person s own knowledge; that, for this reason, there can be no unbiased, a priori valid understanding; that understanding is only a hypothesis; that understanding is a complex, fragile process of reconstructing what the client means; that a therapist can by no means be capable of understanding all clients. Classic understanding concepts in CCT are unpsychological, naïve and empirically wrong and should therefore be urgently revised. But this leads to significantly different conclusions about the clients process and thus to new concepts of therapist behavior and thus to new concepts of the therapeutic process. 3. From non-directivity to process-directivity Clients, on their own, have massive problems clarifying relevant schemata. They get entangled in dysfunctional processes, avoid dealing with negative schemata, etc. So therapists must offer clients specific help. They must produce interventions and apply strategies in order to internalize the client s perspective, i.e. the clients attention must be directed towards internal processes like feelings, thoughts etc.; to activate schemata; 10

11 to channel the client s attention; to develop questions, so called leading questions, that structure therapeutical work and provide a vector of clarification ; to work on the representation of the schema (Sachse, 2003). For this reason, therapists must make specific processing proposals, which must be derived from their understanding of the client. The therapists are thus process-directive, they make specific proposals as to what the client should do next or what he should not do to avoid slipping back into dysfunctional processing patterns. If therapists let the clients go or just follow them, no constructive clarification process will take place. Nowhere is an actualizing tendency less apparent than in the therapeutic process. If the therapist makes no proposals, he leaves the client alone, lets him down, deprives him of potential encouragement and is thus extremely poorly client-centered. The ideological postulates of CCT are a matter of total indifference to clients. What clients want is optimum help, the best available therapy, but not purest theory. Clients do not want religion, they want professionalism. And they are entitled to it. 4. From mere understanding to confrontation Clients are highly ambivalent about clarification processes. From this follows that clients tend to use avoidance strategies in order not to deal with negative content. Clients with psychosomatic diseases even tend to employ avoidance strategies so extensively that processing content becomes virtually impossible. Therefore, therapists should deal specifically with avoidance strategies: They should confront clients with this problem and encourage them to actively explore the reasons for their avoidance tendency. This approach, too, is highly process-directive. Here, therapists make proposals, but do not in any manner force the clients to embark on this process. But the therapist directs the client s attention, he takes on his part of the process responsibility and does not simply let the process run. If the therapist fails to do this, the client could just as well talk to the parking meter. 5. From the purity of the teachings to the integration of effective methods Clarification processes are the basis for the further processing of schemata. So clarification processes are necessary - though sometimes insufficient - methods for changing schemata. Clarification alone sometimes does not lead to a change in schemata. If this is so, the therapist must again make proposals to the client that help him, otherwise the therapist would let him down again (Sachse, 1990b, 1994a). Clients must be encouraged to 11

12 verify schemata; associate schemata with other schemata and resources; test schemata systematically; develop alternative assumptions. For this purpose, Cognitive Therapy provides good therapeutic strategies. These strategies should be integrated in effective CCT. This means that the arsenal of CCT methods should be supplemented with other effective methods. Here it is irrelevant whether or not these strategies fit the classic ideology. What I believe client-centered therapy must do is offer clients the most effective methods, rather than the purest ideology. Ideology has never helped anybody (except the ideologists, maybe). 6. From the homogeneity myth to disorder specificity It is evident from the entire research literature that different disorders function differently from a psychological perspective. So clients with different disorders come into therapy with different starting conditions, thus they need different therapeutic offers. In this case, clientcentered therapy means that: therapists have knowledge of different disorders; the method allows the therapist to develop strategies and interventions that are specifically geared to the starting conditions and objectives of the specific client. CCT can no longer hold fast to the homogeneity myth (Kiesler, 1966); it is a Stone Age myth that is totally untenable in view of the available empirical data. But disorder specificity implies also that diagnosis is needed as part of CCT. Diagnosis makes sure that therapists adopt the best possible client-centered approach! In this case, diagnosis permits to identify at the earliest possible stage what a client needs and to what he will respond. The therapist can thus use the information to act in the best possible client-centered manner. Rejecting diagnosis in CCT is highly unreasonable: Each piece of information that helps the therapist to adjust to his client, is useful, regardless of what source it may come from. 7. From a good person to an expert If you consider how specifically and how effectively a therapist must foster a client in order to stimulate genuinely constructive processes and how badly a therapist can harm the client process by unfavorable intervention, it is clear that the therapist must be an expert. In CCT, the therapist should be a true, genuine person: But this aspect concerns the relationship 12

13 element of the therapy. As far as the clarification element is concerned, the therapist must additionally be an expert on the process. The therapist must make the right processing proposals at the right times; decide between strategies; choose objectives; take decisions based on indications, etc. To be able to do all that, a therapist must have knowledge of psychic disorders; therapy objectives; therapeutic strategies and interventions. A therapist must make decisions, understand, and plan strategies. A therapist must also be able to act strategically on a long-term basis, anticipate the effects of interventions, and look over wide spaces, form models, etc. This means: To be able to act effectively and to foster clients, a therapist must be an expert and act as an expert. As an expert, the therapist must assume his part of the process responsibility during the therapy. 8. From the naïve attitude to the client model For this reason, therapists - using their knowledge - should constantly process information about the clients and form a model - a model of what problems the client has; what objectives can be pursued; how the client structures his relationship with the therapist; how the client processes his problems; how the client could be fostered in the best possible manner. Therapists form models, whether they want to or not (Becker & Sachse, 1997); but the models should not be formed arbitrarily, but in a systematic and disciplined manner and they should be based on psychological knowledge (Becker & Sachse, 1997; Sachse, 1990d, 2000c). The models that therapists form provide the basis for the therapist s understanding, they are thus not in contrast to, but form the foundation of, empathic understanding; for therapeutic decisions; for developing interventions and strategies. Without a model, deliberate therapeutic behavior is not possible. 13

14 9. From following to negotiating In the therapeutic process, the client is the expert on content, while the therapist is the expert on the process. The client determines what is to be processed, what he wants to achieve and to change, etc. The therapist makes clear what objectives are achievable, what the client should process and change, if (and only if!) he wants to achieve specific objectives. In the therapeutic process, these two experts must negotiate; they must establish a consensus, a compromise. In this process, the therapist makes clear what is feasible and what needs to be done in order to reach specific aims: The therapist is the expert on developing solutions and processing content. The client determines whether or not he wants to accept and implement the therapist s proposal. If he rejects the proposal, the therapist has to accept that: Each client has a right to his problems. As for content, the therapist establishes no rules; he does not tell the client what is good and right or how the client should decide. The therapist does not brand thoughts as irrational. The client alone can know what resolutions he can make and stick to. But the therapist can say whether the client can achieve his aim by following a specific course or whether he will get stuck in certain types of processing. 10. From ideology to psychology Rogers attempted to base his system on contemporary psychology. But that was 50 years ago; the assumptions underlying the Rogerian theory are no longer in accordance with actual psychological research. If you want to base CCT on psychology today, you have to fundamentally change many Rogerian concepts, such as: actualizing tendency, experience, attitudes, non-directivity, the assumption that attitudes will lead to changes, and many more. If you fail to do that, you will lose touch with psychology. And then you will no longer practice Psychological Psychotherapy. And that is the other way of gambling away the scientific base of CCT: If you are no longer centered on the underlying science, you will no longer practice a scientifically oriented process. But science moves on: Therefore, CCT must move on, too, so that it will not miss the boat. 14

15 11. From confession to profession CC therapists should define themselves as experts on the process who make a scientifically based proposal for change to their clients, a therapeutic offer that helps clients solve their problems as effectively as possible. In this process, therapists are professionals: They do not live an ideology, but they offer their clients professional help. Ideology does not matter, nor does dogma. What matters is what therapists actually do. And the ethics of psychotherapy demand that they offer their clients a highly optimized psychotherapy. 12. The end of self-deception CCT should give up the still significant level of self-deception; which means that it should revise assumptions that have clearly been proved to be false, such as: The therapy is based on an actualizing tendency. The therapy is non-directive. The therapy is optimally effective. Empathy, acceptance and congruence are necessary and sufficient therapy conditions. You may still believe all that, but you may as well believe that the earth is flat. Insistence on antiquated assumptions has led, and will continue to lead, to a situation where CCT is not taken seriously at academic level. Representatives of classic CCT sometimes criticize the reformers for not being willing to embrace the process and preferring directive methods. Maybe the reformers regard the classic approach as obsolete, restrictive, boring, non-dynamic, inflexible and ineffective. You do not have to be very competent to practice classic CCT; you don t even need to be a psychologist. Maybe that is a little meager for psychotherapy. 15

16 4. A Scientific System or a Sect? If you practice CCT today, you can choose whether to advocate a scientifically supported, psychology-based and empirically founded, developing concept or a classic, unchangeable, highly ideological system that persistently ignores empirical evidence and is developing into a sect. I believe that you have the choice between a scientific system and a sect. If holding fast to conventional ideologies has a central impact on what therapists actually do in the therapeutic process and how they actually structure the therapeutic process, I would like to criticize classic CCT for no longer being state of the art. From a scientific point of view, you should give up numerous Rogerian concepts, such as: actualizing tendency, non-directivity, CCT as a relationship offer, homogeneity myth, rejection of diagnosis, rejection of therapist expert status, rejection of client model forming, the assumption that basic attitudes of therapists alone can bring about constructive changes in clients. But if you stick to all these concepts, you must be prepared to hear from others that you are disregarding empirical evidence; you are ignoring theory-forming in psychology; you can no longer claim to represent a psychological, scientific form of therapy. If you hold fast to theoretically obsolete, empirically falsified assumptions, you are clearly outside the scope of science, because doubting, searching for empirical evidence and further development are the core elements of scientific research. If you no longer allow change to happen, you are building a Chinese Wall against progress. And then you will find yourself in the realm of religion, trapped in a sect. What a sect tries to do is: to preserve a system to the largest possible extent, to shut it off from all change; to keep the teachings as pure as possible and to defend them; to brand any deviation as false, impure and inadequate ; 16

17 to cherish the founder s writings; to subject the founder s writings to an exegesis and debate about what he may have meant by certain statements; to persistently ignore all alternatives and confuting data; to define the system as optimal, perfect and not in need of revision, thus ignoring substantial counter-evidence. In my opinion, some concepts of CCT meet fully this definition of a sect. Of course, you can form a sect and believe all that; but then, I think, you can no longer claim with impunity that what you are doing is based on science, because that is sheer nonsense. And a systematic deception. And: Then the focus is no longer on helping the clients as effectively as possible; the client has degenerated into a marginal figure. Thus the system is by no means client-centered; it is highly ideology-centered. You no longer reflect on how you can help the client or what the client wants (certainly not ideology!), but you reflect on what Rogers thought. I would like to dissociate myself clearly and unambiguously from this development into a sect and do not even wish to be placed anywhere near it. For this reason, I no longer wish to call my approach CCT, but Clarification-Oriented Psychotherapy. 17

18 References: Bastine, R. (1982). Auf dem Wege zu einer integrativen Psychotherapie. In: Psychologie heute (Hrsg.), Neue Formen der Psychotherapie, Weinheim: Beltz. Becker, K. & Sachse, R. (1998). Therapeutisches Verstehen. Göttingen: Hogrefe. Biermann-Ratjen, E.M., Eckert, J. & Schwartz, H.-J. (1995). Gesprächspsychotherapie (7. Aufl.). Stuttgart: Kohlhammer. Bommert, H. (1987). Grundlagen der Gesprächspsychotherapie (4. Aufl.). Stuttgart: Kohlhammer. Bullmann, F. (2003). Hilfreich erlebte Wirkfaktoren in Gesprächspsychotherapie und Verhaltenstherapie. Diplomarbeit, Ruprecht-Karls-Universität, Heidelberg. Elliott, R. (1996). Sind klientenzentrierte Erfahrungstherapien effektiv? Eine Meta-Analyse zur Effektforschung. GwG Zeitschrift, 101, Engelkamp, J. (1984). Verstehen als Informationsverarbeitung. In: J. Engelkamp (Hrsg.), Psychologische Aspekte des Verstehens, Berlin: Springer. Engelkamp, J. (1994). Mentale Repräsentationen im Kontext verschiedener Aufgaben. In: H.J. Kornadt, j. Grabowski & R. Mangold-Allwinn (Hrsg.), Sprache und Kognition, Berlin: Spektrum Akademischer Verlag. Finke, J. (1999). Beziehung und Intervention. Stuttgart: Thieme. Frohburg, I. & Sachse, R. (1992). Steuerungseffekte im Verlauf der Psychotherapie oder: Wann arbeiten Klienten am intensivsten an der Klärung eigener Motive? In: R. Sachse, G. Lietaer & W.B. Stiles (Hrsg.): Neue Handlungskonzepte der Klientenzentrierten Psychotherapie, Heidelberg: Asanger. Gäßler, B. (1994). Psychotherapeuten als Experten. Gedächtnis und Informationsverarbeitung. Regensburg: Roderer. Gäßler, B. & Sachse, R. (1992a). Psychotherapeuten als Experten: Unter welchen Voraussetzungen können Psychotherapeuten die komplexe sprachliche Information ihrer Klienten verarbeiten? In: R. Sachse, G. Lietaer & W.B. Stiles (Hrsg.): Neue Handlungskonzepte der Klientenzentrierten Psychotherapie, Heidelberg: Asanger. Gäßler, B. & Sachse, R. (1992b). Psychotherapeuten als Experten. In: L. Montada (Hrsg.), Bericht über den 38. Kongress der Deutschen Gesellschaft für Psychologie in Trier, 1, Göttingen: Hogrefe. 18

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22 Rombauts & R. van Balen (Eds.), Client-centered and experiential psychotherapy in the nineties, Leuven: University Press. Sachse, R. (1990b). The influence of therapists processing proposals on the explication process of the client. Person-Centered Review, 5, Sachse, R. (1990c). Acting purposefully in client-centered therapy. In: P.J.D. Drenth, J.A. Sergeant & R.-J. Takens (Eds.), European perspectives in psychology, 1, New York: Wiley. Sachse, R. (1990d). Ein sprach- und textpsychologisch fundiertes Verfahren zur Mikro- Prozeßanalyse der Therapeut-Klient-Interaktion: Manual für formale, inhaltliche und Bearbeitungs-Analyse von Klienten- und Therapeutenäußerungen (Finbe-System). Berichte aus der Arbeitseinheit Klinische Psychologie, Fakultät für Psychologie, Ruhr- Universität Bochum, 65, 2. Fassung. Sachse, R. (1990e). Dialog zwischen Expertinnen oder: Das Ergänzungsverhältnis von Verhaltenstherapie, Kognitiver Therapie und Gesprächspsychotherapie. Verhaltenstherapie und Psychosoziale Praxis, 22, Auch erschienen in: Verhaltenstherapie / Therapie Comportementale. Zeitschrift der Schweizerischen Gesellschaft für Verhaltenstherapie, 3, Sachse, R. (1990f). Schwierigkeiten im Explizierungsprozeß psychosomatischer Klienten: Zur Bedeutung von Verstehen und Prozeßdirektivität. Zeitschrift für Klinische Psychologie, Psychopathologie und Psychotherapie, 38, Sachse, R. (1991a). Zielorientiertes Handeln in der Gesprächspsychotherapie: Steuerung des Explizierungsprozesses von Klienten durch zentrale Bearbeitungsangebote des Therapeuten. In: D. Schulte (Hrsg.), Therapeutische Entscheidungen, Göttingen: Hogrefe. Sachse, R. (1991b). Spezifische Wirkfaktoren in der Klientenzentrierten Psychotherapie: Zur Bedeutung von Bearbeitungsangeboten und Inhaltsbezügen. Verhaltenstherapie und psychosoziale Praxis, 23, Sachse, R. (1991c). Gesprächspsychotherapie als affektive Psychotherapie : Bericht über ein Forschungsprojekt. Teil 1 in GwG-Zeitschrift 83, Teil 2 in GwG-Zeitschrift 84, Sachse, R. (1991d). Potentials and difficulties of the process of understanding in psychotherapy: The concept of empathic understanding as viewed in psycholinguistics and cognitive psychology. Berichte aus der Arbeitseinheit Klinische Psychologie, Fakultät für Psychologie, Ruhr-Universität Bochum,

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