Client-Centred Therapy and Psychiatry

A Response to Ivan Ellingham

Lisbeth Sommerbeck
In Ivan’s review (Ellingham, 2003) of the book I have written (Sommerbeck, 2003) Ivan offers a
series of critical reflections on the book. (Like Ivan does, I’ll use our first names, since we know
each other personally.) In this response I’ll address those points of his reflections that are most
important for me to discuss, pointing out where I disagree with Ivan and where I may not have
expressed myself sufficiently clearly, with the consequence that my point of view has been
misunderstood by Ivan and may be misunderstood by other readers of the book.
"Necessary and Sufficient with Drugs and ECT”
Under a section headed "Necessary and Sufficient with Drugs and ECT” Ivan writes that as a
consequence of my way of thinking (using, as an analogy, the concept of complementarity) about
the relationship between Client-Centred Therapy and psychiatry "… she can’t repudiate the
psychiatric view that drugs and ECT are a necessary condition for therapeutic change in her clients.
… she essentially is led to repudiate Rogers’ hypothesis of the six necessary and sufficient
conditions. … She adopts the position that Rogers’ six conditions are necessary but not sufficient –
a seventh necessary condition referring to physical "treatments” such as drugs and ECT needs to be
added for sufficiency.”
First, in this quotation Ivan seems to be writing from the assumption that all psychiatrists think that
all patients (see Sommerbeck, 2003, p. xx for a rationale for my choice of the term "patients” in this
particular context) always need drugs and/or ECT, which is quite simply untrue. Ivan thereby, I
think, discloses a biased attitude towards psychiatrists.
Second, the logical consequence of Ivan’s line of thought would be a heading of this particular
section of his review that read "Necessary and Sufficient with Drugs and ECT and Occupational
Therapy and Physiotherapy and Sensory-Motor Integration Therapy and Art Therapy and
Psychiatric Nursing and …” I could go on, listing all the kinds of treatment my clients may receive
and all the helping relationships they may participate in apart from their client-centred therapeutic
relationship with me, whether these activities are offered and received from within or from outside
the psychiatric context. (Currently I actually have a client who also sees a cognitive/behavioural
I may, of course, have misunderstood Rogers, but I’ve never thought of the hypothesis of the six
necessary and sufficient conditions as an instruction to the client-centred therapist to prevent others
from offering other kinds of help to the client or as an instruction to prevent the client from
receiving other kinds of help. I’ve always thought of the conditions as an instruction to
psychotherapists about the how and what of their particular kind of helping relationship. I therefore
think that Ivan can only make the point he is making by ignoring the distinction between the
psychotherapeutic relationship and other kinds of helping relationships. Now, it seems to me, that
Ivan does this as a consequence of ignoring yet another distinction that I find it important not to
ignore: The distinction between a theory of therapy and the explanatory (personality) theory of why
this therapy effects therapeutic change and, concomitantly, of what psychological health is about
and of the causes of psychopathology. One of the beauties, to me, of, particularly, client-centred
therapy is that I think it can be practiced without a belief in the truth of any such explanatory theory,
including the explanatory theory of Rogers, himself. Ivan, though, apparently thinks that a belief in
the truth of Rogers’ axiom of the existence of the actualizing tendency and of the ensuing
personality theory based on the psychology of self is a necessary prerequisite for the client-centred
therapist. On this rather fundamental point, Ivan and I are in total disagreement. Personally, the
conviction that I find sufficient to practice client-centred therapy wholeheartedly, is the conviction
that human beings are endowed with an inherent pro-social disposition evolved through natural
selection. I am doubtful about Rogers’ explanatory axiom of the existence of the actualizing
tendency and find Skinner’s explanation in terms of operant conditioning more convincing. Ivan,
therefore, is perfectly right when he observes that I deemphasize the concept of the actualizing
tendency in the book I wrote and that I prefer a definition of client-centred therapy that is as
behavioural as possible and thereby expressive of my (behaviourist) view that experience IS
behaviour. As I see it, Ivan raises the question whether it is legitimate to identify oneself as a clientcentred
therapist without "buying” Rogers’ explanatory personality theory. I think it is. Ivan,
perhaps, by ignoring the aforementioned distinction, thinks it is not. (To avoid misunderstandings: I
think Rogers and Skinner are speaking of the same phenomena when they use the terms "conditions
of worth” (Rogers) and "punishing/rewarding consequences of behaviour” (Skinner)).
Finally, in further support of his utterly mistaken assumption that I find drugs and ECT necessary
for my clients, Ivan writes about my clients as if they had no say in the matter, as if they are
passive, victimized recipients of drugs and of ECT being administered to them. I know they are not,
and I find Ivan’s implication that they are to be as biased about my clients as I find his generalised
attitude about my clients’ psychiatrists to be. Furthermore, as a consequence of my conviction that
consistently receiving and following the client with empathic understanding maximally minimizes
the risk of conveying conditional regard, I do not engage in predictive activities with respect to
what may be necessary for my clients apart from unconditional positive regard and empathic
understanding. I leave their efforts to have other needs gratified up to themselves in their various
relationships with other people, and they do much work at clarifying these needs to themselves, and
finding out how to have them gratified, in their sessions with me, whether it be a need for drugs and
ECT to be expressed in their relationship with their psychiatrist, or a need to reject their
psychiatrist’s offer of drugs and ECT, or a need to oppose more effectively their psychiatrist’s
efforts to persuade them to take drugs or have ECT, or a need to stop taking some medication that
their psychiatrist wants them to go on taking, or a need to have another kind of sex with their
partner to be expressed in their relationship with their partner, or a need to have their mother stay
out of their way to be expressed in their relationship with their mother, or … etc., etc. This means,
as I write more extensively about in the book, that I do not step into the role of advocate for my
client, not even on client request, neither with my client’s psychiatrist nor with other people in my
client’s life. (Correspondingly, I do not, with my client, step into the role of advocate for my
client’s psychiatrist, for example, not even on the request of the psychiatrist.) Ivan seems to think
that I let my clients down by this way of working. For me, however, it is an expression of my
respect for the client’s expertise about him/herself in all aspects of his or her life, also when the
going gets rough and it takes some courage. I have given examples, in my book, of the therapeutic
consequences for my clients of my refusal to be their or their psychiatrist’s advocate in their mutual
relationship, but Ivan has, seemingly, ignored this. Sure, psychiatrists, as other authorities, and
people in general, can be more or less manipulative and coercive, but that is, in my experience,
precisely what my clients with increasing self-confidence becomes much better at handling,
themselves, as their therapy with me progresses – just as the theory predicts and research confirms.
The complementarity principle
In the preceding section, I mentioned that I think of the relationship between the psychiatric
approach and the client-centred approach as complementary. The concept of complementarity is
hard to get ones head around, so much so that the American physicist Richard Feynman said that
the person who claims to have understood it has probably not understood anything about it, at all.
Therefore, my explanation of the concept of complementarity, and of the way I use it, may be less
clear than I could have wished. Ivan certainly seems to have misunderstood me, since he apparently
understands me to say that the explanatory (psychological) model of Rogers and the explanatory
(biological) model that is dominant in today’s psychiatry stand in a complementary relationship to
each other, which I do not think that they do. As they are both explanatory models, I see them as
belonging to the same side of the complementarity divide. They both try to find the generalities or
what is average, in the concrete diversity, and they both use these generalities or averages as the
basis for their explanations (of psychopathology). Thereby, they both belong firmly in the natural
scientific tradition that seeks knowledge by analysing, categorising, generalising, hypothesizing,
and experimenting, and they both try to get closer to the truth of how psychopathology comes
about. They are, thus, both concerned with consensual or empirical reality. The Freudian
explanatory model, and the Skinnerian explanatory model belong to the same side of the
complementarity divide; they, too, are, basically, natural scientific models.
This is not the case with the practice of client-centred therapy and, more broadly speaking, with the
hermeneutic/phenomenological approach. They are, like the natural scientific approach, also means
of gaining knowledge, but in this case the priority is knowledge of what is unique and what is
meaningful not knowledge of what is general and explanatory. They are, in psychology, means to
gain knowledge about the private, phenomenological reality of each unique person; they are not
means to get closer to a consensual truth about all persons. It is in this sense that I see the approach
of client-centred therapy, on the one hand, and the approach of psychiatry as well as the approach of
most other helping relationships, on the other hand, as standing in a complementary relationship to
each other. The client-centred therapist, who consistently tries to receive and follow the client with
acceptant empathic understanding, does not intervene in the client’s process from any kind of
preconceived notion, or generalised concept, of what the client might need. This therapist is not
interested in the "average client” of any explanatory model, he or she is interested in the unique
person that the client in front of the therapist is. From this therapist’s point of view it is the unique
client that exists, not the "average client”. It is the other, and precise opposite, way around from the
explanatory point of view where it is the "average client” that is seen, not the unique client. The
psychiatrist, for example, sees a more or less close approximation to his or her idea of "the average
schizophrenic” and treats his/her patient accordingly. Likewise, the lawyer sees his or her client as a
more or less close approximation to the client of case X in the year Y and helps the client
accordingly. The client-centred therapist, contrariwise, sees the client as being unlike any person
seen before, as a person to be known, not as a person already known, and the client-centred
therapist treats the client according to this view that is, fundamentally, diametrically opposed to the
view of the psychiatrist. This is the complementarity divide between two mutually exclusive
approaches and points of views that cannot be integrated, but can be, each in its own way, useful in
their respective contexts. The detailed meaning with the term "complementarity”, in this case, is, in
analogy with the wave/particle duality from quantum physics, that 1) it is false to say that the client
is both unique and average (because unique/average are logically self-contradictory terms), 2) it is
false to say that the client is neither unique nor average (because one can choose a viewpoint where
the client is unique, and one can choose a viewpoint where the client is average), 3) it is false to say,
only, that the client is unique (because, from another point of view the client is average) and 4) it is
false to say, only, that the client is average (because, from another point of view the client is
unique). Thereby the logical possibilities for combinations with respect to the unique/average
duality are exhausted and this is what characterises what one sees from viewpoints that stand in a
complementary relationship to each other. Finally, it belongs to the concept of complementarity that
it is meaningless to ask what the client "really” is, when he/she is not attended to, and that it is the
person who attends to the client who decides whether the client shall be unique or average. (In the
reversible figures of gestalt psychology, that Ivan associates to, the reversibility is, largely, out of
control of the observer (if each figure is endowed with equal figure/ground characteristics),
whereas, in complementary relationships, the "reversibility” of the two complementary viewpoints
is within the control of the observer – and that is, I think, a very crucial difference.)
Cause or causes of psychopathology
I hope, by now, to have clarified what I mean by stating, in my book, that the hermeneutic practice
of, for example, the client-centred therapist and the explanatory practice of , for example, the
psychiatrist stand in a complementary relationship to each other. Ivan, apparently, takes this to
mean that I favour a so called radical post modern relativism where no theory is truer than any
other. That is not the case. Approaches, or points of view, that stand in a complementary
relationship to each other can, per definition, not stand in a relativistic relationship to each other.
Relativistic relationships belong to the same side of the comlementarity divide. Thus, Ivan could,
legitimately, criticise me for saying that Rogers’ explanatory theory of psychopathology is no truer
than a biological explanatory theory of psychopathology – if that was what I said in my book, which
I didn’t. As a matter of fact, the book is about the practice of client-centred therapy in psychiatric
contexts, it is not at all concerned with explanatory models of psychopathology. Ivan is right,
though, if he, between the lines, reads that I do not, as Ivan apparently does, believe that Rogers’
explanatory theory of psychopathology (conditions of worth) goes all the way to tell the full story of
how psychopathology comes about, although I think it goes a long way in that direction. However, I
think that other factors play a role, too: Socio-economic factors, educational factors and, of course,
cultural factors that are important for the definition of what a given culture regards as
psychopathological behaviour. Finally, I can’t disregard what to me seems to be convincing
evidence that biological factors play a role, too, although, in my opinion, they play a much more
peripheral role than they are given by the biologically oriented psychiatrists. Taken together, I think
that the factors that determine what the psychiatry of western societies regard as psychopathological
behaviour are as complexly intertwined as the factors that determine all other kinds of human
behaviour. Such a belief, in a multi-factorial, complexly intertwined causation of psychopathology
is a far cry from the "no theory is more true than any other” radical post modern relativism that Ivan
attributes to me.
The relationship with staff members in psychiatric contexts
With respect to my description, in the book I wrote, of how I typically relate with other staff
members in discussions about the treatment of individual clients (whether therapy clients of mine or
not) it seems to be inconceivable to Ivan that I can be as "staff-centred” in these relations as I can be
client-centred with my clients. Ivan urges me to be "congruent”, assuming that I must experience
some critique in my relation with other staff members that I do not voice. In rare cases I do, of
course, and then I very comfortably voice it or not, depending on context. Mostly, though, I don’t
feel critical of my colleagues, at all. On the contrary, I feel that staff members from other
professions treat patients very well from their particular professional frame of reference, whether it
be as psychiatrist, nurse, social worker, etc. In any case, I have also understood congruence to be an
inner state of affairs, having nothing to do with what one prefers to express/disclose or not.
Since Ivan seems to have misunderstood what I mean with voicing my critique of psychiatry in
appropriate contexts, I’d like to give an example. There is no psychiatrist where I work who is not
aware of my deeply felt critique of psychiatrists’ right and obligation to use force, allegedly for the
sake of the person forced, under certain, legally specified, circumstances. However, I certainly don’t
feel critical of a given psychiatrist’s use of force with a given patient as long as I feel convinced that
what happens is within the specifications of the law that he or she is obliged by. In the rare cases,
when I do not feel thus convinced, I am never the only one who cries out loud. So, normally, I also
try to be as facilitative as I can, in the twice weekly staff meetings on the closed ward, with a given
psychiatrist’s process concerning the use of force with a given patient. In this way I do my best to
ensure that all facets of the situation are considered, before a decision to use force is made, often
with the consequence that the process turns towards a more thorough consideration, and sometimes
choice of, other means. However, at the same time I am, for example, currently engaged in writing
to different relevant organisations about my critique of the use of force in psychiatry. The context of
this writing is that the Danish law about use of force in psychiatry is coming up for revision in the
Danish Parliament in the parliamentary year 2005-2006. Likewise, in other appropriate contexts, I
voice my critique of the domination of the biological explanatory model in psychiatry, of the unholy
alliance between psychiatry and the psycho-pharmaceutical industry, and of the free market policy
with respect to (psycho)-pharmaceutical products – among other things. However, in daily clinical
practice, I have sufficient faith in the pro-social disposition of other staff members and in the
person-centred approach, (because I have, so often, seen it work towards a humanisation of staff
members’ relationships with patients), to approach them in a predominantly person-centred way, i.e.
by being consistently present (my definition of congruence) in my attempt to understand their
processes from within their own professional frame of reference.
Ivan sees this way of relating with staff members as a symptom of mental dissociation. I thought it
was the person-centred approach in practice with other persons than therapy clients. Anyway, I
guess one CAN call absorption in the frames of reference of clients as well as staff-members (and
others, for that matter) for a kind of mental dissociation, since it does tend to exclude anything else
from awareness. In any case, I’m glad to be good at it, whatever it is called.
The disagreement I have with Ivan, concerning the issue of relating with staff members, is, I think,
a very fundamental disagreement about the concept of "congruence”. Ivan seems to believe in the
existence of a "true self”, irrespective of context. I don’t.
Psychological assessment
There may be another issue where I am on a conflicting course with Ivan, namely the issue of
assessment. In his review, Ivan tells the reader that he has learned to seamlessly integrate the
practice of client-centred therapy and psychological assessment, and he also writes that his
judgement of my expert judgement is decidedly shaky. I fail to see the need, in a context of clientcentred
therapy, to integrate psychological assessment and I fail to see what expert judgements of
mine Ivan may be thinking of, since, in my capacity as a client-centred therapist, I don’t make any
expert judgements, and I thought this was very much what client-centred therapy is about: Not
being an expert on the client, but an expert on the method of therapy.
The above 5 points are the main points where I think Ivan goes very wrong in his critical reflections
about my book, and I am amazed that it is possible to go so much wrong.
Ivan seems to be 100% anti-psychiatric, whereas I am probably closer to 50%, since I have seen so
many people really well helped in the psychiatric system (and also many who have not been well
helped or even harmed) – some have even been helped, primarily, by drugs and ECT. This, though,
is, I think, no reason to paint a picture of my book as if it were written by a biologically oriented
psychiatrist, when it is, actually, written by a psychologist and client-centred therapist who sees
curses as well as blessings in the psychiatric system – a fact that I think is very evident in the book.
I am very sorry that Ivan has represented my book as he has, because I think it can only serve to
dissuade person-centred practitioners from seeking employment in the psychiatric system that could
really do with more people of the person-centred orientation.
Ivan’s review tells about Ivan’s relationship, as a person-centred practitioner, with the psychiatric
system. My response to Ivan (and my book) tells another story about this issue. I hope readers may
be stimulated to join the discussion and tell their stories about the relationship between the personcentred
approach and the approach of the psychiatric system – and that these stories will be about a
more shaded relationship than the black/white relationship that I read about in Ivan’s story.