What do you believe to be the necessary and sufficient conditions for real therapeutic change to occur?

It’s the essay title just about every person-centred student has to address at some point in their training: Was Rogers right to claim, as he does in his classic 1957 paper, that the therapist’s (a) congruence, (b) unconditional positive regard, and (c) empathic understanding are necessary and sufficient conditions for therapeutic personality change to occur (along with (d) therapist—client contact, (e) client vulnerability, and (f) the therapist’s communication of these conditions)? Rogers’s hypotheses were based on the available research of his time, and were an amazingly insightful and succinct reading of it. But over 60 years have elapsed since Rogers put forward his position: Does it still stand up to the evidence?

Let’s start with 'necessary’. That means that those first three ‘therapist-provided’ conditions (along with the three ‘relationship’ and ‘client’ conditions) needs to be there for therapeutic personality change to occur. Here, the research suggests a resounding ‘no’. The problem is, it’s evident that therapeutic personality change can happen through a variety of mechanisms where there really isn’t much of a relationship at all. For instance, James Pennebaker has shown that writing about emotional experiences (as with keeping a diary) can be a profoundly therapeutic experience; and there is good evidence that online therapies can be as helpful as face-to-face therapies, often with minimal interpersonal contact. Have you ever watched a film that has had a profound effect on you, or read a book that has moved you to see life in a really different way? If so, it’s really not possible to claim that any kind of relationship factors are necessary conditions for therapeutic personality change.

What about ‘sufficient’? Well, yes, the very latest research does show that each of Rogers’s core conditions are associated with positive therapeutic change. But it’s not necessarily the case from that that they are causing the change. It may be, for instance, that clients who improve then start to feel that their therapists are more accepting and empathic. I know, for instance, that if my doctor gives me some good news, I tend to like them more. And what the evidence also shows is that Rogers’s core conditions are just three of many different relationship factors that are associated with positive outcomes. For instance, alignment on the goals of therapy also seems to be important, and then there’s the therapist’s capacity to deal with ruptures in the alliance, and the use of systematic client feedback. All of these factors are closely related to Rogers’s conditions, but it suggests that the ones Rogers identified don’t have some kind of ‘magical significance’: they’re three factors amongst a sea of inter-related relational variables that all, together, are associated with positive outcomes. Add to that is the problem that, for different clients, Rogers’s therapist-provided conditions may be more or less helpful. For instance, research into empathy shows that, for some clients—highly sensitive, suspicious, and poorly motivated—very high levels of empathy may be counter-productive. Certainly, some clients can feel that a therapist is just too positive, or too in their shoes, or too present and full on. And, finally, there’s some very good evidence, both quantitative and qualitative, that clients can really value, and benefit from, ‘non-relational’ interventions, like normalisation through therapist’s expert knowledge, or ‘behavioural activation’. Maybe the relational elements of these therapeutic encounters are sufficient to bring about some degree of change, but to just focus on that would be to ignore what some clients, themselves, are saying matters most.

The problem with Rogers’s hypothesis is that, in many ways, they’re not very ‘Rogerian’: in the sense that they assume everyone responds in the same way, without taking into account individual differences. When you say things are ‘necessary and sufficient’, the inference is that this is going to be true for us all, and that doesn’t allow for people to respond to therapies in different ways. That’s why John McLeod and I have been arguing that one way of really embodying person-centred principles is through a pluralisticapproach to therapy: acknowledging the many different ways in which clients can be helped and the individual differences in what works for each of us (see blog on Person-centred therapy: A pluralistic perspective). I’m sure that Rogers, like most of us in the person-centred field, would have wanted to respect those differences; and no doubt his ‘conditions’ were an attempt to speak the language of his times: scientistic, nomothetic (i.e., universal), and absolute. In fact, I remember reading somewhere that he does acknowledge that it probably wasn’t the best way of phrasing things. If he’d said something like ‘congruence, empathy, and unconditional positive regard are incredibly important elements of therapy for many people, much of the time’, he’d have been absolutely spot on. It’s a bit less snappy, but 60 years later he would have still been absolutely spot on with what the evidence is telling us, and that’s an amazing thing.

So what would Rogers say now. Reading the evidence, very closely as he did, I’d like to think he’d say something like the following:

What we know is that the quality of the therapeutic relationship is one of the best predictors of outcomes; and a growing body of research is beginning to show that it does, indeed, have the capacity to bring about positive change. For lots of clients, having a good quality therapeutic relationship—empathic, trustworthy, and caring, for instance—can have an enormous impact, just in itself; and for others, it can be an essential vehicle through which other change processes can happen. However, different clients need different things: and it may be that some clients need more: more psychoeducation, or more challenge, or more interpretation. Different people are different. So nothing is necessary and sufficient for everyone. But if you want to practice therapy in a safe and effective way, then establishing an empathic, honest, and unconditionally accepting relationship is, for most clients, one of the best things that you can do.