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CONCEPTUALIZATION AND TREATMENT PLAN 1 1

Case Conceptualization Using Person-Centered Therapy Cara Soto Liberty University

CONCEPTUALIZATION AND TREATMENT PLAN 1 2 Abstract This paper explains the key concepts of the Person-Centered (PC) theory. The founder of PC theory, Carl Rogers had a unique way of creating a safe and trusting relationship with clients during the sessions. He discovered that when in therapy if a client is given empathy, congruence, and positive regard the client can reconnect with their disconnected parts of self and find their own way on their journey to congruence with self. This paper also looks at the compatibility and incompatibility of PC theory regarding Christian beliefs. Rogers’ interventions or methods are explained and applied to the posing client Arthur Dimmesdale, his case is discussed in the paper. A significant amount of research has been done in proving or disproving the validity of PersonCentered therapy. Overall, the therapy when applied in the original form, or integrated into different theories has proven effective with many clients (Moerman, M., 2012; Gibbard & Hanley, 2008).

CONCEPTUALIZATION AND TREATMENT PLAN 1 3 Case Conceptualization Using Person-Centered Therapy The Developer of Person-Centered Therapy Carl R. Rogers is the developer of the Person-Centered Therapy (PC). He received his clinical psychological degree from Columbia University in 1931. He worked for nine years in the Child Study Department of the Society of Prevention and Cruelty to Children in Rochester, New York. It was here that his PC theory was in the beginning stages of formulation. PC therapy slowly evolved over Rogers’ forty-year career in psychotherapy. What did Rogers believe about human nature and the counseling process? Rogers believed that all humans given a supportive environment have the propensity to be good. In Person-Centered (PC) therapy Rogers believed that the client is the center of the psychotherapy, not the therapist. Therefore, the title Person-Centered literally means the person that is being counseled is at the center, they are equal with the therapist. It is assumed that the client has all the resources to move forward with personal growth. Thus, the therapist is there to move forward on the journey with the client. The counselor who is being genuine, by providing an empathetic listening ear and complete acceptance of the client, helps the client explore parts of themselves that they have distorted or denied. The goal is to help the client become congruent with their feelings of their experiences. PC therapy explores a person’s ideal self-concept and helps observe the true self and look for incongruencies between the two. The PC theory proposes that with the counselor’s empathy, positive regard and active listening that the goal of this process will be accomplished by creating a trusting and safe relationship with the client in hopes that they can explore and reconnect with their fractured self.

Studies that have been done that show the efficacy of Person-Centered therapy.

CONCEPTUALIZATION AND TREATMENT PLAN 1 4 Multiple long-term studies have shown the efficacy of Person-Centered (PC) therapy. A five-year study was done though a primary care agency that only used PC therapy. It was found to be effective for clients suffering with anxiety and depression. The study found that over 60% of clients that continued with all the appointments had overall improvement. Furthermore, the study found that PC therapy is effective with people with mild to moderate mental health problems (Gibbard and Hanley, 2008). One interesting study of a women with compulsive buying addiction was followed for a year during which she received PC therapy. She struggled with shame from buying too much and a habit of buying clothes on sale and returning them for full price to stores had gotten her into legal trouble. During her treatment she kept a daily journal and after following through with all therapy sessions there was a decrease in shopping and a more positive overall feeling towards herself (Kellett, et. al. 2020). Scholarly journals recognize the need for more study on PC therapy. There needs to be more current research in the effectiveness of PC therapy (Atzil-Slonim, et. al. 2019). What diagnoses has Person Centered therapy been shown through research studies to be effective with? Person Centered (PC) therapy has been proven to help with anxiety and depression (Gibbard and Hanley, 2008). PC therapy has also been effective in a few different areas including helping in the beginning sessions of counseling with clients suffering from Post-Traumatic Stress Disorder (PTSD). In a research study by Murphy et. al. (2019) they found that starting the first four sessions with PC therapy was beneficial for the client to feel comfortable and be more at ease. Another study suggests that using PC therapy in a school counselor setting would be ideal for the child. It states that PC therapy would provide relationship benefits to the students and

CONCEPTUALIZATION AND TREATMENT PLAN 1 5 make this an easy transition for the student- counselor relationship (Bowers and Lemberger 2016). What makes this theory appropriate for your client and their presenting problems you noted in your first paper? The client is suffering from a fractured self. He is living an incongruent life and as a result is feeling shame, guilt, anxiety, self -contempt, and is suffering from poor physical health. He is looking for relief. He needs someone to have an empathetic, non-judging, listening ear. Person centered therapy can offer empathy which is a factor in self-actualization. According to Elliott et. al. (2018), genuine empathy and care from a therapist can help in the process of becoming congruent with the self. Numerous studies have shown that clients’ experiences of emotions during psychotherapy represent a strong predictor of positive outcomes (Atzil-Slonim, et. al. 2019). It has also been discovered that self-compassion helps to reduce depressive moods (Diedrich, et. al. 2014). With these concepts proven by research it seems that the client will benefit from this form of therapy. What are any potential ethical issues that may arise using this theory with your client? In the book by Jones and Butman (2011) they state that Person Centered (PC) therapy requires that the counselor be fully one’s self while fully relating to the client. The therapist is supposed to be congruent with self and is open to sharing their own thoughts and feelings as part of the process. This can be a tricky step for the counselor, and they will have to remember to uphold the American Counselors Associations (ACA) Code of Ethics A.4.b. (2014) which states, counselors are aware of, and avoid imposing, their own values, attitudes, beliefs, and behaviors. This could pose a problem for the counselor if they are not thinking about the client’s best

CONCEPTUALIZATION AND TREATMENT PLAN 1 6 interest. Which is the counselor’s primary responsibility according to section A.1.a in the ACA Code of Ethics (2014). What are any potential Multicultural issues that may arise using this theory with your client? First, the client is a white male, who is independent and autonomous, he is well educated with a high-status job. According to Jones and Butman (2011), these characteristics are ideal qualifications for Person-Centered therapy. Secondly, the client comes from a culture where relationships have fluid boundaries unlike some cultures who have a hierarchy of age and wisdom. Lastly, the counselor must understand the client’s cultural background. If the presenting client was of an unfamiliar cultural ethnicity the counselor would have to understand the client through the lens of their culture and gain an understanding of their worldview perspective (Swan and Ceballos, 2020). Can this theory be used in crises situations? Yes, it can be used for crises situations. It is effective for clients because the counselor is there to support, they do not try to direct or change the clients experience (Carrick, 2013). Person-Centered therapy has also been used with suicidal clients. When the counselor hears phrases like, ‘I don’t want to live’, they then say, ‘so you want to die’? This somehow engages and encourages the client to open up about their feelings and with the counselors help explores their emotions without judgment from the counselor. For this study a risk assessment was used as an ongoing tool to help bring an integrated approach to the crisis treatment (Moerman, 2012). Interventions Arthur Dimmesdale, the client, is suffering from a fractured self. He had an affair with a married woman, and they conceived a child. He is the minister of the Puritan church in the town

CONCEPTUALIZATION AND TREATMENT PLAN 1 7 of Boston. He will not reveal his secret sin. Dimmesdale is living an incongruent life, a double life, and as a result is feeling shame, guilt, anxiety, self -contempt, and is suffering from poor physical health. Congruence During this part of the process the client will explore parts of themselves that they have denied or distorted. Congruence refers to the counselor’s awareness of what they are experiencing in the moment of counseling. It is the counselor’s job to not put up a front or façade to the client. By the counselor expressing his own feelings and reactions both verbal and nonverbal this appears to help the client identify with their feelings and promotes expression. A client who is experiencing incongruence between self and experience will be rigid and anxious and will constantly be defending experiences that seem incongruent with their perceived self (Murdock, 2005). With Dimmesdale he has a self-perception that he cannot be a sinner. He cannot live with the idea that he has sinned. As a counselor it would be good to react with their own feelings of disbelief and surprise and follow the theme of feelings coming from Dimmesdale as he processes his incongruency towards himself. Positive Regard During this process of counseling the counselor accepts and cares for the client unconditionally. This is a practical skill that can be learned but must be part of the counselor’s genuine response. This unconditional positive regard does not involve shaming, advising, giving interpretations or teaching. All of these create a dependency on the counselor and steal the sense of autonomy (Jones and Butman, 2011). It has been thought that a professional attitude towards clients tends to keep the distance of genuine care and acceptance from the client (Murdock, 2005). When the counselor accepts Dimmesdale and cares for him regardless of what he has

CONCEPTUALIZATION AND TREATMENT PLAN 1 8 done. This models for Dimmesdale what he can do for himself, self-acceptance. As the counselor walks though Dimmesdale’s emotions the counselor can mirror self-compassion and help Dimmesdale reduce his depressive mood (Diedrich, et. al. 2014). Accurate Empathic Understanding Positive regard leads the counselor to empathy, as quoted by Murdock (2005), which is described by Rogers (1980) as perceiving the internal experience of another as if he were that person, and Rogers also saw empathy as a process not a destination. During this time of going into the place of the client it would be in the best interest of both client and counselor for the counselor to reflect on the client’s feelings. The counselor must ask questions for clarification and rephrase what the client is trying to articulate. The counselor must walk with Dimmesdale and entering his suffering with him. This creates a safe place for Dimmesdale to unpack his feelings and sense he is heard and understood. Spiritual Application One of the first spiritual challenges that is presenting itself is that Dimmesdale feels he is unforgivable. To address this first spiritual challenge, the counselor would remind Dimmesdale that he can find grace and forgiveness. Jesus suffered to take our pain. The counselor would have to do this through a series of questions while listening to Dimmesdale and walking with him through his guilt and shame. According to Person-Centered therapy Dimmesdale is moving towards self-actualization and will be searching for growth toward autonomy and move away from external forces that are controlling him (Jones and Butman, 2011). Which is the approval of church members, the towns people and God. The first compatibility between Christianity and Person-Centered therapy is the belief that we are all growing to become more ourselves. We are all unique individuals created in the

CONCEPTUALIZATION AND TREATMENT PLAN 1 9 image of God and he shapes us by being obedient towards him. To counter this first compatibility of PC therapy, we must look at the incompatibility of the theory, we are not inherently good people as PC theory suggests. Left to our own devises we cannot fully know ourselves by ourselves. Our ultimate hope for transformation can only come from God, not ourselves or the counselor (Jones and Butman, 2011). The second compatibility is the journey of self-awareness. We as Christians must look within and examine our hearts that are bent towards evil. We must recognize in ourselves the need of repentance and forgiveness. The second incompatibility can be seen with the PC theory of we know what we are feeling. It is known that Christians sometimes play the role of being happy all the time, hiding our true feelings under the cloak of religiosity as Jones and Butman (2011) pointed out. This leads to a distorted view of reality. We cannot find the true reality from with in ourselves only God is truth speaking. The final compatibility that fits very nicely with Christian view is three therapies: Congruency, unconditional positive regard and empathy. These three envelop the definition of agape love. As Christians this love is experienced directly from God and through God’s people. The final incompatibility expressed through PC therapy is that of one-sided love. PC therapy without the love of God offers empty grace and affirmation. Only true love comes with truth and accountability (Jones and Butman, 2011). Conclusion Overall, this therapy will be of benefit for the client Arthur Dimmesdale. When Christian values and techniques are used with Person-Centered therapy such as God’s agape love and looking inside to see where we need a savior. I believe that with time and unconditional love Dimmesdale will be able to have God mend his fractured self. Just by talking and sharing his

CONCEPTUALIZATION AND TREATMENT PLAN 1 10 pent-up emotions will be a benefit for reducing his anxiety (Atzil-Slonim, et. al. 2019). As Jones and Butman (2011) pointed out our ultimate hope as Christians for transformation can only come from God, not ourselves or the counselor. The most challenging part of using strictly PC therapy is the lack of acknowledging God as the one who heals and restores. We are never able to heal ourselves. We may at time find tools to relieve the pain, but true healing come from God. Jones and Butman (2011) state that PC therapy runs the risk of not understanding or indifference towards the full spectrum of human suffering and misery. A strictly PC therapy counseling for Dimmesdale may enable his lack of willingness to confront his sin. However, with careful integration of biblical knowledge and tools (Jones and Butman, 2011) progress can be made for Dimmesdale towards a positive and forgiving view of himself and God.

CONCEPTUALIZATION AND TREATMENT PLAN 1 11 References American Counseling Association. (2014). ACA Code of Ethics. Alexandra, VA: Author Atzil-Slonim, D., Bar-Kalifa, E., Fisher, H., Lazarus, G., Hasson-Ohayon, I., Lutz, W., Rubel, J., & Rafaeli, E. (2019). Therapists’ empathic accuracy toward their clients’ emotions. Journal of Consulting and Clinical Psychology, 87(1), 33–45. https://doi.org/10.1037/ccp0000354 Bowers, H. and Lemberger, M. E. (2016) A person-centered humanistic approach to performing evidence-based school counseling research, Person-Centered & Experiential Psychotherapies, 15:1, 55-66, DOI: 10.1080/14779757.2016.1139502 Carrick, L., (2013), Person-centered counsellors' experiences of working with clients in crisis: A qualitative interview study. Counselling and Psychotherapy Research, 14 doi: 10.1002/14733145.2013.819931. Diedrich, A., Grant, M., Hofmann, S.G., Hiller, W., Berking, M., (2014) Self-compassion as an emotion regulation strategy in major depressive disorder, Behavior Research and Therapy, Volume 58, 2014, Pages 43-51, ISSN 0005-7967, https://doi.org/10.1016/j.brat.2014.05.006. Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399–410. https://doi.org/10.1037/pst0000175.supp (Supplemental) Gibbard, I., Hanley, T., (2008), A five-year evaluation of the effectiveness of person-centered counselling in routine clinical practice in primary care. Counselling and Psychotherapy Research, 8 doi: 10.1080/14733140802305440.

CONCEPTUALIZATION AND TREATMENT PLAN 1 12 Jones, S., & Butman, R. (2011). Modern psychotherapies a comprehensive Christian approach (Second edition.). IVP Academic. Kellett, S., Oxborough, P., & Gaskell, C. (2020). Treatment of compulsive buying disorder: Comparing the effectiveness of cognitive behavioral therapy with person-centered experiential counselling. Behavioral and Cognitive Psychotherapy, 1-15. doi:10.1017/S1352465820000521 Moerman, M., (2012), Working with suicidal clients: The person-centered counsellor's experience and understanding of risk assessment. Counselling and Psychotherapy Research, 12 doi: 10.1080/14733145.2011.628031. Murdock, N. (2005). Theories of counseling and psychotherapy: a case approach. Merrill/Prentice Hall. Murphy D, Elliott R, Carrick L. (2019) Identifying and developing therapeutic principles for trauma‐ focused work in person‐ centered and emotion‐focused therapies. Counseling Psychotherapy Res. 2019;19:497–507. https://doi.org/10.1002/capr.12235 New International Version. (2001). Women’s Devotional Bible. Zondervan. Swan, A. M., Ceballos P., (2020) Person-centered conceptualization of multiculturalism and social justice in counseling, Person-Centered & Experiential Psychotherapies, 19:2, 154167, DOI: 10.1080/14779757.2020.1717981...