The expression toward a therapist of feelings linked with earlier relationships is known as

1.01.3.3 Treatment Strategies

While all humanistic-existential-experiential approaches aim to increase client self-awareness and self-determination, the treatment strategies they use can differ. In client/person-centered therapy, as previously mentioned, the accent falls on expressing genuineness, unconditional positive regard, and empathy in the therapeutic relationship. So, the question is how the therapist expresses these attitudes. Well, it is more of a mindset rather than a collection of techniques. For example, as therapists, we are not encouraged to express unconditional positive regard directly, with statements like “I care about you”, as this may seem artificial. Rather the therapist conveys positive regard by expressing warmth, but also respect—for instance, by keeping appointments, or remembering and elaborating on what the client has said before (Sommers-Flanagan and Sommers-Flanagan, 2004). Also, at first glance, the concept of genuineness can be interpreted as lack of censorship on the part of the therapist, but this is by no means what Rogers meant. Actually, the therapist has to refrain from expressing thoughts or reactions which are not in the benefit of the client. The therapist's attention should be focused on the client as much as possible (and not on herself), as the name, client-centered therapy suggests. If, when attuned to the client's perspective and experience, the therapist has an emotional reaction (such as compassion or surprise), than she can convey it to the patient, if that is in his benefit (Sommers-Flanagan and Sommers-Flanagan, 2004). In Roger's words, empathy “involves being sensitive, moment to moment, to the changing felt meanings which flow in this other person, to the fear of rage or tenderness or confusion or whatever, that he/she is experiencing” (Rogers, 1975, p. 4). Empathy involves focused attention on the client's experience and can be conveyed (depending on the content) via client-oriented behavior (e.g., nodding, smiling, open posture, interjections like “uh huh”), paraphrasing (restating what the client has said), reflection of feelings (e.g., It sounds like you are feeling really overwhelmed), first-person quotations (e.g., I guess you're saying “Why would I even try”), deepening reflections (e.g., the client says “I was sad”, and the therapist repeats “You were sad”, as to encourage the client to stay with his feelings). Rogers' reflective listening techniques were further incorporated and developed in other humanistic approaches, like motivational interviewing (Miller and Rollnick, 2002), but also in most future therapeutic orientations.

In experiential and existential therapies, the purpose is emotional expression, exploring disowned parts of ourselves, and constructing new meaning. Therapists within these approaches tend to be more confrontative than in client/person-centered therapy and may use provocative techniques that challenge the patient and evoke powerful emotional reactions. However, the techniques are neither the purpose nor the essence. Even in Gestalt, the therapy which left us with a plethora of experiential techniques, they are only recommended when strictly necessary. In Perls' words, “a technique is a gimmick. A gimmick should be used only in the extreme case. We've got enough people running around collecting gimmicks, more gimmicks and abusing them” (Perls, 1969). We briefly present some experiential techniques, as summarized by Sommers-Flanagan and Sommers-Flanagan (2004):

Staying with the feeling—encouraging the patients to stay with their feelings instead of avoiding them by asking questions like “What are you feeling right now” or asking clients to give a “voice” to their feelings (e.g., what would your anxiety say?).

I take responsibility for…—the client uses this statement in relation to whatever content she is expressing in therapy (e.g., I feel sad, and I take responsibility for it).

Playing the projection—the client is instructed to play the feature he projected onto someone else. For instance, if the client is bothered by entitled behavior in another person, he has to reenact this entitlement.

The reversal technique—the clients get in touch with parts of themselves which have been previously minimized, ignored, or denied. For example, a silent patient is asked to speak loudly, a passive individual to act aggressively, or a reserved person to act forthcoming.

The exaggeration experiment—the clients are encouraged to exaggerate their subtle non-verbal behaviors (e.g., frowning, biting one's lip). This technique is meant to bring awareness to what we involuntarily do.

The empty chair technique/dialogues—the client has to give voice to the conflicting parts of her polarities (e.g., the Top Dog and the Under Dog, the people-pleaser and the uncaring rebel) and switch chairs as she acts these roles. The purpose is usually for these sides to compromise and proceed toward an internal resolution. Another version of this technique implies the patient to play both her role as well as the role of a significant other while paying attention to the feelings that come up.

The relationship and therapeutic alliance

The relationship between analyst and patient is of paramount importance in psychodynamic work, as it is here that the patient will demonstrate how they interact with the world. Seeing this in the here-and-now through the transference affords both parties an opportunity to explore how the patient's internal world is made manifest and provides a more immediate basis for interpretations to be made.

A specific component of the patient–therapist relationship is the therapeutic alliance, comprised of three components:

the working alliance – the mutual conscious investment of patient and therapist in the therapy;

mutual affirmation – similar in nature to Carl Rogers’ ‘unconditional positive regard’; and

empathic resonance.

The alliance is of significant import as its quality has been shown to predict treatment outcome (Horvath & Symonds 1991). Traditionally it has been regarded as being distinct from the transference relationship as it is comprised of the more rational and mature part of the collaborative process between patient and practitioner (Krupnick 1996), although in reality there will be crossover of the two (Greenson 1967).

The Person-Centered Therapist

Similar to working with a humanistic therapist, engaging in therapy with a PCT therapist will be a unique experience. There will be individual differences across therapists based on their personalities and life experiences. However, these therapists will share a basic set of tenets or beliefs that guide their work. They will value and work to build trust within the relationship while engaging in what Rogers described as facilitative conditions for growth. These conditions are genuineness (congruence), acceptance (unconditional positive regard), and empathic understanding (Rogers, 1957, 1979).

PCT therapists are committed to being genuine or real during therapy sessions. They are not interested in presenting as experts of the client’s life or intent on teaching the client the errors of his or her ways. Nor do they apply a façade to mask human emotions or responses. Instead, they bring themselves and all they have learned as humans to the therapy encounter. They remain present and attentive to the client. Their years of education and work on their own personal and professional issues in therapy and supervision or through other experiential and contemplative practices inform who they are as therapists.

The therapist’s nonjudgmental acceptance of the client is the second of Rogers’ optimum conditions for change. Over the years, this has also been referred to as unconditional positive regard, caring for, or prizing of the client. Humanistic therapists work at developing, sustaining and sharing this attitude of prizing or valuing others as it is essential to the change process. Unconditional positive regard can be viewed in therapy sessions as the client explores both the perceived positive and negative aspects of his or herself, and the therapist accepts and cares for the whole person without judgment. This model of therapy suggests that it is often during these moments of feeling accepted even while being seen, flaws and all, that the client is able to make some movement toward positive growth.

Empathic understanding is also central to the work of the PCT therapist (Elliott et al., 2011; Rogers, 1975). It involves the therapist actively listening to the client, genuinely trying to understand the other’s inner world and frequently checking in to confirm accurate understanding. It is then adjusting or correcting the therapist’s perception of the client’s report when inaccurate. A PCT session rich in empathy will involve a therapist feeling close enough or attuned to the client to almost feel his or her emotions when shared. But, it is simultaneously being far enough away to know that those emotions belong to the client and not to the therapist. It is the therapist’s sensitive, active listening that can allow the client to feel safe in opening up and sharing.

2 Basic Therapeutic Concepts

The following are the fundamental concepts of person-centered psychotherapy:

(a)

An actualizing tendency which is present in every living organism, expressed in human beings as movement toward the realization of an individual's full potential.

A formative tendency of movement toward greater order, complexity, and inter-relatedness that can be observed in stars, crystals, and microorganisms, as well as human beings.

Trust that individuals and groups can set their own goals and monitor their progress toward these goals. Individuals are seen as capable of choosing their therapists and deciding on the frequency and length of therapy. Groups are trusted to develop processes that are right for them and to resolve conflicts within the group.

Trust in the therapist's inner, intuitive self.

The therapist-offered conditions of congruence, unconditional positive regard, and empathy:

Congruence has to with the correspondence between the thoughts and behavior of the therapist, who is genuine and does not put up a professional front.

Unconditional positive regard, also identified as ‘caring,’ prizing,’ and ‘nonpossessive warmth,’ is not dependent on specific attributes or behaviors of the client.

Empathy reflects an attitude of profound interest in the client's world of feelings and meanings, conveying appreciation and understanding of whatever the client wishes to share with the therapist.

Self-concept, locus-of-evaluation, and experiencing are basic constructs which emerge from the client's own interaction with the world.

The self-concept is made up of the person's perceptions and feelings about self. Self-regard or self-esteem is a major component of the self-concept.

Locus-of-evaluation refers to whether the person's values and standards depend on the judgments and expectations of others, or rely upon his or her own experience.

Experiencing has to do with whether the person, in interacting with the world, is open and flexible or rigid and guarded.

The Internal Frame of Reference (IFR) is the perceptual field of the individual, the way the world appears, and the meanings attached to experience and feeling. It is the belief of person-centered therapists that the IFR provides the fullest understanding of why people behave as they do, superior to external judgments of behavior, attitudes, and personality.

6 Impact on the Professions

More than anyone, Rogers helped spread professional counseling and psychotherapy beyond psychiatry and psychoanalysis to other helping professions. While not the first to use the term ‘client’ for the recipient of therapy, he popularized it, emphasizing that ‘a person seeking help was not treated as a dependent patient but as a responsible client,’ and that those in psychological distress were not necessarily ‘sick,’ requiring treatment by medical specialists. Rather all people could be helped by the growth-producing conditions of empathic understanding, unconditional positive regard and congruence, and professionals from many fields could be trained to provide these conditions. Thus counselors, social workers, clergy, medical workers, youth and family workers, and other helping professionals could employ counseling methods and client-centered attitudes in their work. Rogers' books Counseling and Psychotherapy (1942) and Client-Centered Therapy (1951) described the principles of effective therapy and presented ample case studies from recorded sessions to illustrate his points. In 1982, surveys in the Journal of Counseling Psychology and American Psychologist still ranked Carl Rogers as the most influential author and psychotherapist.

Rogers also impacted the helping professions through leadership in many professional associations. He served on the executive committee of the American Association of Social Workers, was Vice-President of the American Association of Orthopsychiatry (social workers), and President of the American Association of Applied Psychology, the American Psychological Association, and the American Academy of Psychotherapists, among other distinguished positions.

Attitude

Why do we talk about attitude if we are interviewing a suspect, witness, or victim? If you want information from an interviewee, you need to know what attitude you should have with that person in order to obtain the response or information that you are seeking.

If the response you seek in an interview is full and open cooperation, you must maintain a positive attitude toward each and every interviewee. Each of us has a history filled with experience, which creates bias and prejudices. That experience will determine the preconceived opinions and perceptions with which we go into each interview. I encourage you to be honest with yourself and understand how and why you have formed your specific opinions, so that you can conduct each interview in a fair and impartial way, treating each interviewee with a level of respect. In addition, understand how your discriminatory actions affect others.

Showing respect means remaining calm, actively listening, and maintaining a positive attitude. By having confidence in your skills and ability, you will display that you are self-assured. Neighborliness will sow positive seeds of your attitude, persistence, and general determination along the investigative path. Sensing your helping, friendly attitude, interviewees will probably comply as expected. A positive attitude is always effective, no matter what your objective.

Perceptive interviewees can sense your attitude as it is expressed through the formulation and presentation of your questions and by the way you listen to the responses. They are keenly aware of verbal and nonverbal signals expressing negative attitudes. If you ridicule or degrade interviewees, you will only promote antagonism.

Characteristics of a positive attitude are warmth, empathy, acceptance, caring, and respect. You should learn to have and project these qualities because they will help you become a proficient interviewer.

These are three important qualities to incorporate into your positive attitude:

Congruence. To be in congruence with yourself means to be aware of and comfortable with your feelings and to be able to communicate constructively with interviewees in a way that expresses your humanity. To be in congruence with the interviewee means to recognize and accept the human qualities, needs, and goals that we all share.

Unconditional positive regard. Just as a parent expresses unconditional love for a child, you should strive to display a positive regard for interviewees, without reservations or judgments. Regardless of the inquiry and even when dealing with unsavory interviewees, treat everyone as a valuable human being. Develop a genuine liking for people, and be tolerant of human weakness. When you’re dealing with interviewees you consider repugnant, do not show how you really feel. When your inner feelings are critical of the interviewee’s behavior, put on a convincing show of acceptance of or tolerance for their behavior. This show is intended to encourage interviewees to let down their guard when talking with you. As I said earlier, identifying your prejudices and biases will help you understand the people you interview and avoid prejudging them.

Empathy. Empathy is the ability to identify with someone else, to understand their thoughts and feelings from their perspective. Pay attention as interviewees express themselves verbally and nonverbally so that you can pick up on their messages. Interviewees often express some deep emotional hurt that influenced their behavior in some way. By comprehending those hurts and putting them into your own words, you show that you are deeply tuned in, and this expresses closeness and caring.

Controlling your negative feelings throughout an investigation and with interviewees will be invaluable. Avoid being condescending or patronizing. These feelings will only cause antagonist behavior. Keep in mind, your goal is to get information that will help solve a case. Obtaining the facts and not being judgmental will affect the outcome. If you have negative feelings, you can change them if you really desire to change. As a professional, you can make a commitment to modify your attitudes and thus change your behavior to become a more effective interviewer. To change your attitudes, you must first change your feelings or your thinking. Authoritarianism, which breeds resentment, retaliation, and reluctance or refusal to cooperate, is based on your biases and prejudices.

A significant challenge is to become aware of your own strengths and limitations. The more aware you are of your good and bad qualities as an investigator, the more likely it is that you will make changes to improve yourself. Having a positive attitude is the first important step you will take to prepare for interviews.

II. Theoretical Bases of the Working Alliance

The concept of working alliance originated in psychoanalytic psychotherapy that is designed to make unconscious conflicts and feelings conscious. The analytic patient relates to the analyst in a distorted manner that mirrors these unconscious conflicts. In 1912, however, Sigmund Freud also posited a positive relationship between the analyst and patient that was based in the reality of their work together. This relationship later became known as the working alliance.

To humanistic therapists who believe that people are capable of helping themselves if they are provided with a facilitating relationship, the working alliance is both necessary and sufficient for client improvement. According to Carl Rogers in 1957, the therapist was responsible for creating this facilitating relationship by demonstrating empathy, genuineness, congruence, and unconditional positive regard toward the client. Within this accepting environment, the client was then able to achieve self-acceptance and self-actualization. This relationship would then generalize to other relationships outside of therapy. Thus, for Rogers, the working relationship was directly responsible for client improvement.

Behavioral and cognitive-behavioral therapy, which are based on learning principles, did not originally address the client–therapist relationship. In 1977, however, the Association for Advancement of Behavior Therapy (AABT) published ethical principles for behavior therapists. These principles emphasized client agreement with the goals and methods of treatments that are important components of the working alliance. Thus, most behaviorists and cognitive behaviorists stress the importance of the working alliance.

The working alliance is just one term for the collaborative relationship between client and therapist. Different theorists highlight different aspects of the alliance, and as a result, it is sometimes referred to as the helping alliance or therapeutic alliance. In 1979, Bordin put all the elements of the working alliance together into one conceptualization that applied to all types of theories and therapies. He defined working alliance as a bond between client and therapist and an agreement on the goals of therapy and the tasks necessary to achieve those goals.

Theoretical Bases of the Working Alliance

The concept of working alliance originated in psychoanalytic psychotherapy, which is designed to make unconscious conflicts and feelings conscious. The analytic patient relates to the analyst in a distorted manner that mirrors these unconscious conflicts. In 1913/1966, however, Sigmund Freud also posited a positive relationship between the analyst and patient that is based in the reality of their work together. This relationship later became known as the working alliance.

To humanistic psychotherapists who believe that people are capable of helping themselves if they are provided with a facilitating relationship, the working alliance is both a necessary and sufficient for client improvement. According to Rogers (1957), the psychotherapist is responsible for creating a facilitating relationship by demonstrating empathy, genuineness, congruence, and unconditional positive regard toward the client. Within this accepting environment, the client is able to achieve self-acceptance and self-actualization. This relationship then generalizes to other relationships outside of therapy. Thus, for Rogers, the working alliance was directly responsible for client improvement.

In contrast, behavior and cognitive-behavioral psychotherapists have historically tended to focus on specific techniques rather than the relationship between psychotherapist and client. In practice, however, behavioral therapies, such as dialectical behavior therapy, acceptance and commitment therapy, and functional analytic psychotherapy, rely heavily on the psychotherapist-client alliance to facilitate client change (Grosse Holtforth and Castonguay, 2005; Lejuez et al., 2005).

The working alliance is just one term for the collaborative relationship between client and therapist. Different theorists highlight different aspects of the alliance, and as a result, it is sometimes referred to as the helping alliance or therapeutic alliance. In 1979, Bordin put all the elements of the working alliance together into one conceptualization that applied to all types of theories and psychotherapies. He defined working alliance as a bond between client and psychotherapist and an agreement on the goals of therapy and the tasks necessary to achieve those goals.

In their 1985 article on the relationship in psychotherapy, Gelso and Carter emphasized the importance of establishing a positive working alliance early in treatment so that the alliance would sustain the relationship through the difficult periods to come in treatment. They believed that the alliance becomes disrupted in the middle phase of therapy when most intense work on behavior and attitude change is undertaken. The alliance was then assumed to recover to more positive levels later in therapy.

6.07.11 The Therapeutic Relationship

Following Rogers, EFT therapists are fully present with their clients (Geller and Greenberg, 2012). They are attentive, curious, accepting and fully immersed in their interactions, moment-to-moment, with their clients. They are attentive and without judgment as they try to enter their clients' worlds as they try to see and feel into their experience. They are open and receptive as they try to establish safety so their clients can allow their vulnerability into awareness to process their painful life experiences and transform their negative emotions. This sense of interpersonal safety allows for exploration and diminishes feelings of threat and anxiety. Porges (2021) polyvagal theory posits that when human organisms feel received and connected to another their brains neuroceive a state of safety that allows them to relax and engage in therapeutic work. Neuroception, a seventh sense posited by Porges, enables organisms to internally sense situations of danger and threat or safety and security. A therapists receptive, open concern as expressed by their vocal and non-verbal behavior contributes to clients' sense of safety and provides the necessary scaffolding to engage in treatment.

Empathy is an essential aspect of EFT treatment both in terms of the therapists' attitude toward the client but in terms of specific response modes. EFT therapists are empathically attuned to clients' affective states. Tracking and following clients' emotions closely in a session while conveying a deep understanding of the meaning of clients' experience using empathic reflections. Therapists' empathy draws on their cognitive understanding of what it is like to “walk in their clients' shoes” as well as their capacity to resonate to the emotional impact of the events in their clients' lives. The capacity to resonate deeply and to share their understanding of their clients' lived experience contributes to a number of important processes of change. First, it builds the therapeutic relationship by forging a strong working alliance as the therapist communicates an understanding of the clients' struggles and goals and in addition facilitates; second, it contributes to clients' affect regulation in the moment and over time as being seen and understood modulates the intensity of an experience and facilitates the processing of that experience providing direction for future action; third, empathic reflections help clients to deconstruct their world views, identify their assumptions and beliefs about themselves and others and understand how these may be restricting them and inhibiting change. Empathic reflections provide an opportunity for clients to reflect on their experience in order to perceive new ways of viewing it as well as acting in the world; fourth, the experience of being understood by another without judgment but with concern leads to the internalization of empathy and self-compassion for the self so that all of experience is available to awareness and can be integrated in ways that transform clients' self-organizations and ways of relating to themselves and others.

Unconditional positive regard along with a deep-seated understanding of the clients' moment to moment experience is seen as transformative in EFT. As therapists communicate a positive and sincere valuing of the other just as he or she is without any requirements to be different organismic change is likely to ensue (Gendlin, 1982; Rogers, 1959). Unconditional Positive Regard, is core to client-centered theory (Bozarth, 2001; Freire, 2001), and is a basic underlying condition in EFT as clients become more aware of their feelings, their responses to the world and their self-organizations in the presence of an empathic and accepting other who values the person. Like their client-centered counterparts, EFT therapists are open, receptive, curious, warm and valuing of their clients. They trust that UPR along with clients feeling understood, thus known and seen by the other, will release the clients' potential for growth and reconfiguration.

Trust in the organismic growth tendency is fundamental to the approach with therapists offering the relationship conditions along with different tasks and ways of working to facilitate clients' access to their inner bodily felt sense so that they can symbolize it in awareness. The relational experience of being fully known and accepted by another is viewed as healing allowing clients the space and opportunity to adopt new ways of being and relating to self and other. Clients are seen as complex with hidden dissociated aspects of experience outside of awareness that need to be reclaimed and integrated into the whole. UPR is expressed with empathic response modes that convey validation, understanding, and affirmation. Other response modes demonstrating a more exploratory intent are important to support the clients' attention to their inner experience so they can symbolize it and know it better bringing it into the light of awareness so as to become more congruent and integrated and facilitate the ongoing flow of experience and being.

Rogers (1957) emphasized that the relationship conditions need to be offered congruently and experienced as sincere for the other conditions to facilitate organismic growth and transformation. It is easy to understand this emphasis as feigned regard or understanding would not likely be experienced as empathic or accepting but rather may be seen as manipulative and shallow. Thus, Rogers underscored the importance of therapists being congruent with their inner experience matching what they are communicating to clients. When offered congruently and genuinely, empathy and UPR can be received and experienced as validating and provide a credible anti-dote to conditions of worth and ways of being that have been hidden or dismissed and silenced in order to guarantee protection, love, acceptance and approval.

EFT therapists make a distinction between genuineness and transparency. Genuineness describes a state of congruence between the therapists' inner feelings about the client and their outer expression. It has been noted that being genuine does not mean that therapists reveal all their feelings to their clients, but rather that they are aware of their feelings and do not pretend or deny them to themselves (Mearns and Cooper, 2005). Lietaer (1993, 2001) distinguishes between inner and outer genuineness. The former refers to the degree to which therapists have conscious access to, and are receptive to the full flow of their own experiencing in the session. This he defines as congruence, in contrast, to outer genuineness or transparency, which refers to more explicit communications by therapists that are revealing about their perceptions, attitudes, and feelings. EFT therapist practice both types of genuineness as they demonstrate their unconditional positive regard for their clients and support the unfolding of their inner process and share their perceptions about their clients' process, express concern at times when clients are being intensely self-critical and provide psycho-education and suggest different tasks in the session. Transparency is also encouraged to repair ruptures that occur in the session.

The introduction of process direction and tasks in EFT highlights the need for therapists' to be responsive as they attune to their clients, moment to moment in the session. Responsiveness has been characterized as an attitude or a willingness to be flexible and fluid (Watson, 2021). EFT therapists are constantly assessing and adjusting to their clients' states of readiness as they suggest tasks and listen empathically to their clients' concerns. They attend to their clients' emotional experience during the session carefully tracking its ebb and flow as they follow and at times direct the process. They continually attend to clients' feedback in order to adjust and modulate their responses to fit their clients' needs moment to moment and find the most fitting response.

In describing therapist responsiveness in EFT, Watson (2021) notes that therapists are aware of balancing the needs and goals of the client with their treatment methods, their moment by moment observations, their place in the treatment trajectory, their assessment of the quality or state of the therapeutic alliance and the interpersonal pulls experienced by therapists in the session. This delicate balancing act is informed by different markers that provide clues about clients' emotional processing capacity, the quality of their self-organizations, their understanding of their history as revealed by the completeness and coherence of their narratives, their attachment histories, as well as their own sense of autonomy and mastery. All this information and possibly more that is beyond conscious awareness (Schore, 2003, 2019) informs EFT therapists' responsiveness moment to moment in the session and over the course of treatment (Watson, 2021).