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This paper is an early descriptive report on psychotherapy with schizophrenics in a research project sponsored by Carl R. Rogers. The project employs many psychometric and interview measures, a matched control group, and complete tape recordings of the therapy interviews. The project is not yet completed and hence it is not yet established that effective psychotherapy is taking place. Meanwhile much is being clinically observed and learned. Therapists are modifying the client-centered way of doing therapy.
The paper will trace these developments in terms of the trends and theories of the client-centered orientation, but clearly, what is occurring is related to a wider context of present trends in the field of psychotherapy generally. I will therefore begin by quoting some writers outside the client-centered orientation, whose descriptions of their practice indicate at least three trends which are shared by several orientations: increasing emphasis on (1) the personal relationship; (2) the therapist's spontaneity and genuine expressiveness; (3) the subverbal, affective, preconceptual nature of the basic therapeutic communication. Fromm-Reichmann (1959) writes:
The doctor should offer his presence to lonely patients, first in the spirit of expecting nothing but to be tolerated, then to be accepted simply as some person who is there. The possibility that psychotherapy may be able to do something about the patient's loneliness should, of course, not be verbalized at this point. To offer any such suggestion in the beginning of one's contact with an essentially lonely patient could lend itself only to one of two interpretations in the patient's mind: Either the psychotherapist does not know anything about the inextricable, uncanny quality of his loneliness, or he himself is afraid of it.
Whitehorn writes:
B physicians (unsuccessful with schizophrenics) had a tendency either to be passively permissive or to point out to a patient his mistakes and misunderstandings . . . whereas the A physicians (successful with schizophrenics) did little interpretation or instruction, but did express personal attitudes fairly freely on problems that were being talked about by the patient, and did set limits on the kind and degree of obnoxious behavior permitted.
Whitaker, Warkentin and Malone (1959) write:
Nonverbal communication is of primary importance. The patient must avoid intellectual verbiage, lest it be a barrier to the unconscious-to-unconscious affective relationship between therapist and patient.
Silence as such can be a valuable medium for the conduct of the communication between therapist and patient.
The therapist is not simply a projective screen but an active participant in a person-to-person relationship in which he participates with as few technical maneuvers as possible. The therapist's effort is to communicate as fully as possible his feeling responses to the presence of the patient, and his experiences in this relationship.
The trends of current client-centered therapy to some extent resemble the observations of the above-quoted authors and of others. Thus, this paper will report much that is not new. On the contrary, the very recurrence of similar experiences and methods in different orientations would seem to point toward phenomena that deserve attention. In the observations of these [Page 206] authors, and, as I shall report, in our own observations, effective psychotherapy with schizophrenics appears to be a largely personal, expressive, and concretely experiential or subverbal process.
Before I can report the most recent developments in client-centered therapy, I must report the trends and changes in method which were already occurring a few years ago, before the research with schizophrenics began. At that time, along with most other orientations, client-centered therapy was becoming less sectarian, less formal, more personal, more concerned with feeling and immediacy than with verbal content or verbal reflection.
Three lines of modification, especially, were already being made at that time:
1. Seeman (1956) and a number of others found fault with the description of the client-centered response as a "reflection of feeling." In various ways the range of therapist response behavior was being widened. Rogers (1957, 1959), especially, widened the scope to include as therapeutic all modes of responding which could manifest three basic therapeutic attitudes: "empathic understanding," "unconditional positive regard," and "genuineness." An unlimited range of therapist behavior might implement and communicate these attitudes. Rogers hypothesized that therapy would take place if these attitudes were present and communicated to the client. Thus basic therapist attitudes, rather than any specific "client-centered" behaviors, were thought to be the essential therapeutic factors.
2. In a second line of modification during the last few years, Butler (1958) and others held that therapist spontaneity is related to success in therapy. Rogers formulated as one of the three basic therapeutic attitudes that "the therapist is congruent (genuine) in the relationship." Of course, genuine expressiveness does not mean that the therapist spends most of the hour verbalizing each of his own feelings (most often he would be genuinely experiencing the client's expressive behavior). However, there has been a striving for undefensive transparency and genuineness of the therapist as the person he is, free of professional or personal artificiality.
3. A third modification was the increasing tendency (Gendlin & Zimring, 1955; Hart 1961; Rogers 1959) to view therapy in the client as consisting of feeling events, rather than conceptual insights. The theory of "experiencing" (Gendlin, 1961a; 1962) emphasized that one moment's concrete feeling process could implicitly contain many psychological contents. It might be impossible to conceptualize all of these, yet the client can feel them all as a directly sensed referent within himself. Therapeutic responses aid the client to refer directly to his present feeling process, and to maximize and intensify this process (Rogers, 1959). The interactive conditions of the therapy situations were seen as constituting new experiencing of a fuller, more immediate manner (Gendlin, et al., 1960).
As I shall now show, these three earlier lines of modification in the client-centered approach have grown to be the major characteristics of therapy with schizophrenics.
What is it, in the schizophrenic individual's response to psychotherapy, that has so accelerated just these already incipient lines of development? I will mention four well-known characteristics of the way in which many schizophrenic individuals respond to psychotherapy:
"Nonmotivation." Clients were selected according to criteria of the experimental design—age, sex, social class, length of hospitalization, degree of disturbance—as crosscutting variables. When two individuals who matched each other on all these variables were found, a coin was flipped to determine which was a no-therapy control, and which would receive therapy. This method obviated the more usual se- [Page 207]lection for therapy. Usually individuals who are responsive to staff and become known to them are assigned to psychotherapy. In this way motivated people most often select themselves. We expected and desired a group of clients whose prognosis would not be biased favorably by such self-selection. We more than accomplished this aim.
The majority of the clients who were selected for therapy did not desire it, resisted it, often refused to meet the therapist, and made it difficult for therapy to begin or to continue (Gendlin, 1961b).
Silence. The second characteristic reaction, encountered with the majority of these clients, was silence. This was not the occasional periods of silence which we associate with deep therapy, but continuing silence, interview after interview, often for the whole interview with the exception of a few sentences.
"Nonexploration." A third characteristic concerns the nonexploratory, often non-inward character of what is said. The verbal therapeutic process often seems absent. Often there is a refusal to own feelings explicitly, even though they are just then being implied. There is a high degree of externalization. Problems and interests are located in others and in external circumstances. [2]
Even when there are brief periods of seeming self-exploration, or of deep verbal communication, these do not go to make up a continuing process.
The next meetings may again be barren of deep verbal communication, as if nothing had happened. The person does not seem to be engaged in an exploration of his own to approach his subjective problems. Verbally, there is irregular and nonexplorative emotional expression.
Intense subverbal interaction. A fourth characteristic is the intensity of subverbal interaction. It often seems that the individual has given up the niceties of civilized society, and of verbal or consensual checking. Subverbal impressions guide him. If it is his impression that the therapist's face reflects a dislike, a disturbance, a rejection, his response is instantaneous and likely to be total. For example, when I hesitate for a moment in the midst of saying something, my client waves me away. It is as if all in an instant my ambivalent, semiunconscious difficulty in formulating my message is sufficient for him to back away from it. Slight movements on either of our parts constitute an intense subverbal conversation. Early in therapy my interest and curiosity in him is often visibly hard for him to bear. More verbal later on, he can say: "Your ears are too big," or less dramatically, "I don't know if I should say anything or not. You're too curious." In many interactions I cannot know whether what I subjectively live with the client is anything like what he feels, but I know that we are engaged in an eventful and deeply felt subverbal interaction.
As I mentioned earlier, the client-centered method is no longer defined in terms of specific techniques or modes of response, but rather in terms of certain basic attitudes (Rogers, 1957, 1959). Many different orientations, techniques, and modes of therapist response could manifest these attitudes. Therefore, the attitudes I will now describe are not limited to client-centered therapy, yet they alone define "client-centered therapy."
The therapist who endeavors to share the psychotic client's perceptions and feel- [Page 208]ings sees little therapeutic value in explanatory concepts. These do not help him reach the individual's own experiencing. Because the hospitalized person is so often "administrated," his case "disposed" in some way, without much reference to his own experiencing, there is a tendency to discuss him in terms of diagnostic explanatory concepts. In terms of such concepts we have generalized knowledge. In contrast, the therapist who endeavors to be "empathic" focuses his attention on the individual's own experiencing, in so far as the therapist can sense it.
2. Often in a hospital setting the behaviors, aggressions, manifest symptoms, and act-outs become all-important foci of attention. The hospitalized client is often punished or corrected. The therapist, on the contrary, seeks to perceive with the client on the client's side (becomes his "lawyer," as Betz and Whitehorn [1956] suggest), and has a warm "regard" for him as a person. It is just as true of psychotics as of others that as one gets to know the person more deeply one likes him very personally, if concerns with outside factors do not interfere.
3. In a hospital setting there is a remarkable isolation of the client. Not only are his interpersonal contacts narrowed physically, but his contacts are also qualitatively limited, since often he is not responded to at face value. His words are often not taken as a serious message from a person. Similarly, it is common for professional people to withhold their own actual responses and to substitute some professionally appropriate stock response. In contrast, if the therapist attempts to be "genuinely" himself, and self-expressive, then he is foremost a human being capable of shattering the schizophrenic's isolation; he brings a direct human contact. And, although the schizophrenic may not be able to meet this human approach, he has nevertheless in the therapy situation an equally human role. He may fill this role or leave it empty, but it is constantly present as a fully human role.
The hurt and isolation of schizophrenics generally, and the nonvoluntary way in which these clients were assigned to psychotherapy, would account for their characteristic refusals, silences, and absence of verbal exploration. Yet I think the attitudes of these therapists also tended to bring out more strongly just such reactions, and thus led to modifications in the mode of psychotherapy.
A therapist who is accustomed to initiating therapy by responding to the client's motivations and feelings is sure to be strongly affected by the client's unwillingness to meet with him. Such a therapist is sure to feel temporarily deprived of the basis upon which he works.
Similarly, a therapist whose main focus is to share the client's actual subjective experiencing—a therapist who cares little for external explanations and behavioral corrections—is most likely to note, as a striking characteristic, the client's lack of subjective focus.
The therapist who is accustomed to aiding self-exploration by empathic response will also be especially struck, and put at a loss, by the great amount of subverbal communication. This is just the sort of communication with which he is trained to empathize, yet the psychotic individual often does not intend to explore—or verbally formulate—these communications. As the therapist attempts to understand verbally, the client withdraws the more.
The therapist who is accustomed to value the client's frequent private search within himself is not likely to interrupt silences. Naturally, he finds that silences stretch into the whole hour and sequences of hours.
I believe that therapists with other methods also encounter the client reactions I described, but perhaps they would not seem as striking as they do when viewed in terms of the client-centered approach.
It might be simplest to describe our experiences by saying that when therapy did not seem to be going well, the therapists [Page 209] felt a need to alter their modes of approach. First there are the conflicts that occur in the therapist because of these characteristic patient reactions, conflicts which make it impossible for the therapist to retain his customary attitudes. He comes to feel quite nontherapeutic and seeks ways to alter the situation so as to restore within himself his more familiar therapeutic attitudes. He must find different behaviors so as to regain the same attitudes which he is accustomed to as therapist. But the obvious alternative ways of behaving also do not restore his own old attitudes. The result is a process (still going on here) of sensitively evolving quite new alternatives of therapeutic respondings where there previously appeared to be no good alternatives.
There are three stages in this process.
The client is silent, or talks of trivia. Attempts to verbalize his implicit communications make him angry, fearful, or withdrawing; or, as we try to respond to a deeper level of feeling, we find that the client simply has not meant to look at himself more deeply—and misunderstands us. We have all sorts of impressions and images of what the client feels, since subverbally he does communicate. We wonder what to do with all this richness of events which occurs in our own moment-to-moment experiencing, as we sit quietly or converse superficially. We feel much empathy but can show little. As we go along on a casual level, or in silence, we wonder if we aren't allowing ourselves to be just as helpless as this fearful person. We are in conflict, not knowing whether to push harder or to attempt being even safer. We blame ourselves for too much helpless waiting, then, minutes later, for too much interruption, pressure, and demand. We wonder whether the client is doing anything significant with us, whether we are failing him. We become impatient and angry at giving so much inward receptivity while so little of it seems communicated. We value deeply what little or trivial communication he gives us, and we do not want to push that away. Yet we feel dishonest when we seemingly assent to silence or to this trivial level of communication. Obviously, in such a condition, we feel quite unfamiliar to ourselves as therapists. In order to attempt to restore the inward condition we are familiar with as being therapy, we come to behave in unfamiliar ways.
The client refuses to meet with the therapist. Shall he be coerced, or should the relationship be allowed to end before it has really begun? Neither alternative is acceptable. The therapist goes to meet the individual on the ward (coercion of a sort), but leaves him free to walk away. Now the client's participation does not commit him, nor does his walking away constitute a committed refusal. The therapist will visit again later in the week, and will do so explicitly because he wants to. This leaves the client's end of the relationship indeterminate until he determines it. The therapist states his own desire to meet with the client, his interests and feelings in this regard, in spite of negative reaction or lack of reaction. Certainly, the therapist in these ways takes more of the initiative than he usually would. Yet he attempts to find modes of taking initiative which are based on his own feelings, and which do not take the place of those initiatives which might later arise in the client. It is a peculiar and subtle resolution of the dilemma. In certain respects the therapist take more initiative (for himself), yet in other respects he takes less initiative than ever (for the client). Not even the client's commitment to try to form a relationship is assumed, or demanded.
The same trend of more expressiveness with less imposition applies not only to our mode of initiating psychotherapy, but also to our whole way of working during psychotherapy. We find that even when we cannot know what the client is thinking and feeling, we can respond to him. If he is silent, I, as therapist, may be quite in the dark as to what he is thinking and feeling. I only know what I am thinking [Page 210] and feeling, and how I imagine him. As I express my present feeling and my vague images of what may be happening between us now, a very personal quality enters into my expressions. I am giving words to my ongoing experiencing with him. There is a quality of personal risk and openness in my saying these things. There is a quality of gentle closeness in giving directly of my imaginings and feelings. In expressions I often state also my intention in saying what I say, and my unsureness concerning what is happening in him. I clearly say: "this is what is happening in me now," or "this is what I imagine is happening in you (or between us), but I can't be sure." The client lives in a responsive context made up of my person and my openly expressive interaction with him. Yet, his side of the interaction may be quite tentative, implicit, until he wishes to make it explicit as his.
Similarly, the externalizing, event-reporting client stirs in me many feelings for him, and images of him. I desire to hear from him more deeply, welcome him more personally. I can say this, and say it at every juncture at which I particularly feel it. In his descriptions of incidents, I sense him involved in many ways. I can express these (as imaginings of my own). I come to have more, and more often, a sense of the person he is which he omits from his reports of events. I become the one who expresses the feelings, who complains, cries, justifies, understands the private side of things which is misunderstood. I gently express my bafflement or surprise at the dilemma he is in. But these are my expressions as an open and expressive person.
I express myself in a fashion (and this takes a few steps of self-attention each time) which clearly states my feeling (not some judgment or deduction) and is based on my feelings for him and my desire to be close to him. As with the silent person, so also with the event reporter, I give voice to what I experience or imagine in him or in the events he reports. I voice it as my momentary inward process as we interact. One might say that these therapists frequently establish and continue relationships by means of expressing themselves openly and genuinely. This procedure seems to leave the inarticulate and fearful person free, yet gives him a relationship at a time when he still cannot do much to form or maintain one.
The relatively subtle changes in emphasis which constituted modifications in the client-centered approach prior to its application with psychotics have become major observable developments. To conclude this report, I want to draw them together. The three directions of modification I mentioned were: (1) attitudes, rather than client-centered behavior, as therapeutic factors; (2) genuine expressiveness of the therapist; (3) experiencing (the preconceptual feeling process) constitutes therapy, rather than verbal self-exploration. In a theoretical formulation just brief enough to suit this early stage of observation, I might formulate these three directions in one formula: The therapeutic attitudes (1 above) manifest themselves in interactive behaviors through genuine therapist self-expression (2 above), and this open interaction itself affects the nature of the client's present experiencing process (3 above) so that in spite of threat and withdrawal he may find his experiencing occurring more optimally and in interaction.
Complete research results must be awaited for the experimental and matched control groups, before we can know whether effective psychotherapy with schizophrenics is taking place. The present paper is therefore a report of current practice. The evaluation of its effectiveness is still an open question.
Psychotherapy generally, with any type of population, seems to involve not only verbalization, but more fundamentally, the client's inward reference to, and struggle with, his directly felt experiencing. The individual's inward data, concretely felt, seem to be the actual stuff of psychotherapy, not the words. It may be especially [Page 211] true for the schizophrenic, but it seems true for everyone, that felt experiencing is meaningful in a preconceptual rather than only a conceptual way. Felt experiencing can be endlessly differentiated and conceptualized, yet it is concrete and never really consists of words and concepts.
The schizophrenic may show this especially, since he is so often lost and selfless, and the preconceptual meanings of his experiencing at first seem to him so removed from other persons and so incommunicable that silence or a few nonlogical words are the only possible expression. Very often one can see that his few statements arise from a very eventful, concretely felt process—and that the interactions with the therapist are affecting or enabling this process. In principle, psychotherapy generally, and not only with schizophrenics, may be considered fundamentally as a process of felt experiencing in the context of interpersonal responses. If that is correct, the client and therapist process described in this report would be in the most basic sense the same as that which occurs in any psychotherapy.
Received October 15, 1961.
Betz, B., & Whitehorn, J.C. The relationship of the therapist to the outcome of therapy in schizophrenia. Psychiatric research reports of the American Psychiatric Association, 1956, 5, 89-106.
Butler, J. M. Client-centered counseling and psychotherapy. In D. Brower and L. E. Abt (Eds.), Progress in clinical psychology, Vol. III. Changing conceptions in psychotherapy. New York: Grune & Stratton, 1958.
Ellinwood, Charlotte. Some observations from work with parents in a child therapy program. Counseling Center discussion papers, Vol. 5, 18. Univer. of Chicago Library, 1959.
Fromm-Reichman, Frieda. Psychoanalysis and psychotherapy. Selected papers of Frieda Fromm-Reichman. D. M. Bullard (Ed.), Univer. of Chicago Press, 1959.
Gendlin, E. T. Experiencing: A variable in the process of therapeutic change. Amer. J. Psychother., 1961, 15, 233-245. (a)
Gendlin, E. T. Experiencing and the creation of meaning. New York: The Free Press of Glencoe, 1962.
Gendlin, E. T. Initiating psychotherapy with "unmotivated" patients. Psychiatric Quart., 1961, 35, 134-139. (b)
Gendlin, E. T., Jenney, R. H., & Shlien, J. M. Counselor ratings of process and outcome in client-centered therapy. J. clin. Psychol., 1960, 16, 210-213.
Gendlin, E. T., & Zimring, F. M. The qualities or dimensions of experiencing and their change. Counseling Center discussion papers, Vol. 1, 3. Univer. of Chicago Library, 1955.
Hart, J. The evolution of client-centered therapy. The Psychiatric Inst. Bull., Wisconsin Psychiatric Institute, Vol. 1, 2. Univer. of Wisconsin, 1961.
Kirtner, W. & Cartwright, D. Success and failure in client-centered therapy as a function of initial in-therapy behavior. J. consult. Psychol., 1958, 22, 329-333.
Rogers, C. R. The necessary and sufficient conditions of therapeutic personality change. J. consult. Psychol., 1957, 21, 95-103.
Rogers, C. R. A theory of therapy, personality, and interpersonal relationships as developed in the client-centered framework. In S. Koch (Ed.), Psychology: A study of a science, Vol. III. Formulations of the person and the social context. New York: McGraw-Hill, 1959. Pp. 184-256.
Rogers, C. R. A tentative scale for the measurement of process in psychotherapy. In E. A. Rubinstein, and M. B. Parloff (Eds.), Research in psychotherapy. Washington, D. C.: American Psychological Assn., 1959.
Seeman, J. Client-centered therapy. In D. Brower, and L. E. Abt (Eds.), Progress in clinical psychology, Vol. II. New York: Grune & Stratton, 1956. Pp. 98-118.
Whitaker, C. A., Warkentin, J., & Malone, T. P. The involvement of the professional therapist. In A. Burton (Ed.), Case studies in counseling and psychotherapy. Englewood Cliffs, N. J.: Prentice Hall, 1959.
Whitehorn, J. C. Studies of the doctor as a crucial factor for the prognosis of schizophrenic patients. Paper from the Henry Phipps Psychiatric Clinic of the Johns Hopkins Hospital.
Many people have been awaiting with interest an article of this kind. We have known that Rogers and his colleagues were working in therapy with schizophrenic persons. It was intriguing to speculate about the developments in therapy method which were emerging from the crucible of this experience.
[Page 212]Gendlin has given us the initial answers to this question. Some of the answers may seem baffling. What Gendlin describes is in some respects an exact mirror image of client-centered therapy as it has usually been known. One of the defining characteristics of client-centered therapy (indeed, the literal meaning of its title) lay in its emphasis upon the internal frame of reference of the client. Gendlin portrays the counselor as attending at times, not to the client's inner life but to his own.
This would seem to be a strange reversal of emphasis. Yet the shift does not imply a change in therapeutic direction but only underlines the central continuities in therapeutic theory. For the therapeutic relationship, if it means anything, means real communication between two people. One of the major tasks of the therapist is to restore the integrity of communication, which in the client has been shattered by experiences of danger from others. The therapist can do this best by communicating with immediacy and integrity himself. This is what I think Gendlin is telling us here. The content or focus of communication may shift according to circumstance but the immediacy and genuineness are invariant.
There are implications in all of this to which attention may usefully be drawn. One chief implication concerns the increasing awareness by counselors of the differentiation between the basic intentions of the therapist and the instrumental means—i.e., the specific technical therapist behavior—by which the intentions are realized. This is a useful distinction to make. Its practical utility lies in its implicit recognition that different therapists are bound to develop personal response styles as different instrumental means to implement the same basic intentions. This is an especially important consideration for the person learning to be a counselor, because it frees him from the lockstep effect of learning a "therapeutic method" and fosters experimentation with personal ways of implementing basic hypotheses about therapy.
If Gendlin's paper answered some questions, it also served to heighten issues about which general agreement is some distance away. Gendlin pointed to some emerging commonalities among therapeutic approaches in working with the psychotic person. These commonalities are useful to understand. It is equally important to maintain our perception of the continuing differences among approaches, not because there is any virtue in "schoolishness" but because these differences may contain unanswered validity questions about therapy. One very lively issue implied in Gendlin's paper is client-centered therapy's continuing struggle to be nonintrusive. This characteristic has been one of the hallmarks of client-centered therapy. There was no issue in the earlier days when therapist involvement was low. But one of the more striking developments in client-centered therapy has been its shift from detachment to involvement. Is it not difficult for a therapist to be highly involved and yet remain unintrusive? I suspect that the client-centered therapist faces some real existential struggles around this issue.
A final issue which remains to be resolved is the place of cognitive processes in psychotherapy. The growing emphasis of client-centered therapy on immediate experiencing places the fulcrum of therapy at the preconceptual level. The role of cognitive reorganization thus becomes more peripheral. This development is especially intriguing because it emerges in the context of a theory built around the importance of the self concept, a construct which has strong cognitive undertones. My own thought on this issue is that the idea of preconceptual experiencing claims current emphasis as an emerging concept, but that the theory in the long run will revisit the cognitive realm and continue to view therapy as a blend of both affective and cognitive reorganization.
Julius Seeman
George Peabody College
[1] The project was supported by the Society for the Investigation of Human Ecology and the Wisconsin Alumni Research Foundation. Currently it is supported by the National Institute of Mental Health. The project is being carried out at Mendota State Hospital, Madison, Wisconsin, with the collaboration of W. J. Urben, Superintendent, and G. Tybring, Clinical Director.
[2] In this respect these schizophrenic clients resemble the clients who usually fail in client-centered therapy according to the accurate predictions of the studies with the Kirtner Scale of first interview ratings (Kirtner & Cartwright, 1958). The failure-predicting end of the scale indicates external location of problems and lack of inward exploration.
Another group of individuals who usually pose difficulty for client-centered therapy are the parents described by Ellinwood (1959), who bring their children to play therapy and seek help for themselves also, but do not want or expect this help to be psychotherapy.
If the developments in psychotherapy with schizophrenics, described here, are successful, they may apply also to these groups of clients and to many others.
