Psychotherapy

Humanistic Psychotherapy

Mark Dombeck, Ph.D.

We've arrived at the end of the road, my friends. That is, at least, the end of the road for this recent series of essays detailing the technical contributions of the various major schools of psychotherapy. The present essay is the last scheduled stop for that tour. My last essay titled, "Boundaries and Dysfunctional Family Systems" describing the contributions of the Family Systems school of therapy. Prior to that we covered behavioral and cognitive behavioral approaches, and two psychoanalytic techniques (the analysis of repression and transference). Prior to that, I provided an overview of the various schools of therapy by way of an introduction. We're winding down now, and also coming full circle. The essay that started this series off in my mind had to do not with therapy technique, but with what are called the non-specific factors – the parts of therapy that have to do with the quality of the therapy relationship and how that relationship promotes growth and healthy development when it is genuine and real. Those non-specific factors that were so important in that first essay came from the approach to therapy that I've saved for last, namely the humanistic approach to therapy that we're covering now.

potted plants in a rowIn my introduction to this series of essays, I gave a name to each school of therapy so as to identify that school's unique personality. The behaviorists were engineers, the psychodynamic psychotherapists were philosophers, etc. I called the humanists Gnostics in that little scheme because, as I thought about them and their uniquely personal version of therapy (which will shortly be described in some detail), it struck me that the humanistic therapists shared an ethic with religious gnostic groups who believe that true wisdom become possible only through personal direct experiences and not through the application of dogma.

One way to understand the humanist contribution to psychotherapy is to contrast their approach to therapy with the approaches characteristic of the other major therapy schools. Despite their differences, those other schools of psychotherapy all had in common that they traditionally regarded patients as rather passive beings with problems who required the intervention of experienced expert therapists before they could be expected to get better. Another way of saying this is that those other schools of therapy have tended to follow the traditional medical model, more or less, in that they saw themselves as treatments for illnesses. When you see psychotherapy as essentially a treatment for disease, you end up seeing human problems as illness states, patients as passive carriers of illness, and the goal of therapy as one of illness removal.

When it first appeared on the scene, late to the game in the 1950s and 60s, the humanist approach to therapy was in stark and revolutionary contrast to the prevalent passive-patient, disease-centric view of mental illness. The basic motivating idea behind the humanistic approach was that patients were active and responsible beings who participated in creating or at least in maintaining their mental illness states. As active participants in maintaining their own problems, patients could chose to undo some or all of their problems under the right conditions. Because the humanists saw patients as active and powerful creators and maintainers of their own problems rather than as passive victims of those problems, they necessarily took a different approach to therapy than previous therapists. The goal of the humanistic therapy became to set up the conditions that would enable patients to choose to help themselves, rather than to require a doctor to administer interventions. The therapy became person-centered, respecting the power of the person in therapy to choose change or not, rather than technique-centered as previous therapies had been. The humanistic therapy also began to focus more on helping patients to achieve better general mental health and wellness states and less on removing specific mental illnesses.

The humanist vision of active, empowered patients who could cure themselves was founded on a particular set of assumptions about human nature. The humanist therapists made the assumption that people were for the most part essentially good, or at least neutral beings, and not beings who were essentially evil or sinful. They also assumed that people were actively involved in constructing and explaining the meaning of events in their lives every second of their lives. This is to say, the humanists took a developmental and largely secular view of human nature. Humans had instincts and biological drives but not original sin. They were meaning making creatures whose capacity for meaning making evolved over time. They could either develop into the good and healthy people they were designed to become (by God or evolution, makes no difference) or alternatively, to have their development derailed by abuse, neglect or accident of some sort and end up less than healthy or outright dysfunctional.

In the humanistic vision, human dysfunctions are caused by a faulty or interrupted development process; essentially human problems are due to immaturity, generally of the social/emotional variety. The goal of a humanistic therapy is thus to promote social/emotional maturity and growth. By helping patients to resume their derailed developmental processes in healthy directions, patients are helped to grow up and out of the immature mental and emotional states that cause them to be in pain themselves and to inflict pain upon others.

Various influential humanistic therapists came up with multiple approaches to the actual therapy process, all of which were designed to help promote patients' maturity and proper social/emotional development.

Psychologist Carl Rogers' 'person-centered' or 'client-centered' therapy made therapists' task one of creating an optimal therapy relationship with the patient. If the patient and therapist could mutually create the proper sort of relationship with one another, the conditions would become solid for optimally promoting that patient's growth. Rogerian therapy makes the therapist out to be a sort of gardener, you might say, and the patient into a sort of plant that the gardener will be tending. If the gardener can help place the plant into the right soil and give it the proper water and light, that plant will very likely start to grow. Patients are not plants, of course, and I certainly don't mean to suggest that anyone in therapy is a "vegetable" (ha ha). But patients are like plants in that if they are planted and cared for well (e.g., provided with an optimal therapy relationship), they may start to grow.

Rogers was clear on describing the elements that went into providing an optimal therapy relationship capable of helping patients to thrive and grow. The therapist needs to be utterly genuine, transparent and honest in terms of his or her interactions with the patient. He or she needs to want to be there, and to be helpful. He or she needs to find a way to genuinely care for each patient who is worked with. Therapists must also provide confidentiality and security; the therapy relationship must function as a bounded environment where secrets shared are kept. Any limits to confidentiality need to be described up front so that they do not come as a surprise to the patient. All of these things must be in place so that the patient can come to truly trust the therapist and share their inner experiences with the therapist. The patient's ability to trust in the therapist is the magic ingredient that gets growth started.

Trust is not quite enough to get growth moving properly, however. There is also the matter of helping to herd the patient, in sheep-dog style, towards the emotional problems that he or she is facing but maybe doesn't want to deal with just yet. The reason for this emotion focus in humanistic oriented therapies is based on another assumption the humanists made, namely that the cause of many of the developmental delays plaguing their patients had to do with emotional blocks and traumas of varying sorts; ungrieved losses, embarrassments, secret shames and guilts on the milder side all the way through to true traumas of the variety that might cause PTSD in an unlucky person, or contribute to an addiction. Because these traumas and shames are painful, patients often do not much want to talk about them, even when they know it is in their best interests to do so. Therapist herding behavior is thus designed to help push patients to deal with their painful and avoided emotions sooner rather than later.

Different schools of humanist therapy take different tacts with regard to herding patients towards emotionally charged topics. The gentle client-centered Rogerians pioneered that now clichéd phrase, "how do you feel about that". Alternatively, the less tentative practitioners of Gestalt Psychotherapy (pioneered by the brilliant and narcissistic psychiatrist Friedrich "Fritz" Perls) encourage a more direct approach designed to draw people out of their heads and into their bodies so that their avoided emotions are actually experienced.

The most famous Gestalt Psychotherapy technique for helping people get out of their heads and into their emotions is known as the "empty chair". The empty chair technique is essentially a directed visualization technique wherein a therapist directs a patient to imagine someone they are in conflict with as though they were sitting in an empty chair in front of the patient. The patient is encouraged to describe and visualize the person as though he or she is actually in the room. Once the visualization appears to be solid, the patient is encouraged to start speaking to the visualized person in the empty chair, telling him or her all the things that have not been said in reality. Patients often feel very funny doing this exercise, but that is mostly because it rather quickly tends to suck people into experiencing the emotions associated with having the actual conversation. It is not uncommon for people to start crying during this sort of thing, and therapists have to be careful to not set up a situation where patients get too freaked out. Emotion for emotion's sake is not the goal here. Instead, what is desired is a sort of behavioristic Systematic Desensitization effect wherein the feared and avoided emotion becomes less scary after it is experienced and no longer needs to be avoided so much .

Though humanistic therapy leaders like Rogers and Perls succeeded brilliantly in calling attention to the vital importance of the quality of the basic therapy relationship in promoting therapeutic change, they were somewhat less successful in creating an all-purpose therapy approach for the ages. It has become clear over time that humanistic therapy in the pure original formats practiced in the 1960s have a somewhat limited application. They are most useful for purposes of promoting growth and social/emotional development in people who are basically on track and have their stuff together more or less already (e.g., people who need therapy the least). They can be very useful as a variety of supportive psychotherapy for people who are grieving, for instance, or as a basis for treating problems that are essentially about overcoming shame and guilt and getting back in touch with organic motivations. If you're hung up because you want to be an artist but you became a doctor instead to please your daddy, humanistic therapy is for you.

Humanistic therapies are not useful at all when people have problems that are essentially medical in nature (such as schizophrenia, bipolar disorder, etc.) or problems that are characterized by moderate to severe mood or anxiety problems, which are best treated with one of the empirically supported (read: behavioral) psychotherapies.

In modified form, humanistic therapy has utility for treating some of the personality disorders. Keep in mind, however, that once modified, such therapies are no longer pure humanistic therapies, but rather something new. Psychologist Marcia Linehan's Dialectical Behavioral Therapy, for instance is in many ways a mash-up of humanistic and behavioral approaches that happens to work well for treating borderline personality disorder and similar conditions that have to do with poor emotional control.

What most practicing therapists seem to have realized, essentially, is that the basic flaw in the original humanist approach is that their assumption that people will be able to fix themselves if given the proper environment is wrong when people don't already have good coping skills. If, as a therapist, you teach your patient good coping skills (by way of literal teaching and/or use of therapy interventions) and also provide a humanistic therapy environment at the same time, you really have something there.

Few practicing therapists today call themselves humanists. Nevertheless, the humanist school has had a tremendous influence on the other three main schools of therapy and how they practice therapy. Just about all forms of therapy practiced today have taken a page out of the humanistic play book and pay careful attention to optimizing the therapy relationship and to creating conditions that will promote patients' deserved trust in their therapists. The various therapy professions have gone so far with this agenda as to have written some of the core humanist principles into their ethical codes as well. The humanist school is thus essentially nowhere and everywhere today. An interesting place for a therapy approach to be.




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