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Sam Driscoll

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A Critical Evaluation of the Use of Expressive and Creative Therapy in Person-Centred Counselling

June 16, 2017

 

Is person-centred therapy best understood as a science, or an art? Can it be considered person-centred to facilitate creative and expressive methods of therapeutic work? And if so is to do so indicative of having a belief in the insufficiency of the core conditions? And how can this creative therapeutic environment be created? These questions will be explored within my work below, but it is worth noting that understanding the therapeutic process is phenomenological in nature; there are no absolutes. Therefore, what will be presented will simply be symbolic of my critical perception of the therapeutic process, demonstrating my own understanding of person-centred theory and what it means to work creatively.

 

I hold a strong belief that person-centred therapy is best understood as an art, rather than a science. A statement that could cause some controversy when it is considered that Rogers was heavily influenced by a scientific paradigm (Kirschenbaum and Henderson, 1990; Barret-Lennard, 1998; Cooper et al, 2013; Lago and Charura, 2016). But ultimately it is a therapeutic approach that cannot be manualised, there is no person-centred map that someone can follow (Mearns and Thorne, 2000). The core conditions may be described as three different attitudes, but this is a simplified understanding of person-centred theory. Within each attitude a continuum exists. Unconditional Positive Regard (UPR) has different facets to it, from acceptance to prizing (Kirschenbaum and Henderson, 1990; Cooper et al, 2013; Tolan, 2017). Empathy can be communicated either reductively, concordantly or complimentarily (Mearns, Thorne and Mecleod, 2013; Cooper et al, 2013), and it has different experiential aspects, being symbolised as having a blend of cognitive, emotive and somatic elements associated with it (Cooper, 2008). And then with congruence there is an aspect of self-awareness, being genuine and an element of transparency associated with it (Rogers, 1967; Lietaer, 1993; Bozarth, 1998).

 

Plus there is the fact that these attitudes can create tension within a practitioner. To be transparent could mean a counsellor feels it is appropriate to share a judgement with the client, yet being non-judgemental is another aspect of UPR. Demonstrating that the core conditions become more complex the further they are examined; meaning that person-centred therapists tend to practice in creative and expressive ways by default.

 

The point being made is that person-centred therapy is not as simple as practitioners from other modalities may presume. It is more complex than scientific application. Mearns and Thorne believe this perceived oversimplification may be due how Rogers’ delineated these therapeutic attitudes so others could understand the person-centred therapeutic process (Mearns and Thorne, 2000). Which was delineated to fit into a mainstream scientific paradigm of cause and effect, as evidenced by Rogers’ language, “If these six conditions exist, and continue over a period of time, this is sufficient. The process of constructive personality change will follow.” (1957). So if we bring in an artistic paradigm, it could be implied that the core conditions are similar to the primary colours, in the fact they can blend and manifest as different qualities, with therapeutic presence being the palette they manifest from.

 

Research suggests that while there is a relationship between aspects of therapeutic presence and Rogers’ therapist-offered conditions of empathy, congruence and unconditional positive regard, presence is a distinct quality that provides a foundation for these conditions. (Cooper et al, 2013, p. 210)

 

It could be implied that acceptance and empathy facilitate a process of relating, whilst including congruence facilitates a safe encounter. This primary colour analogy also supports the manifestation of the different resonances a therapist may experience; the blending of forms of relating with congruence. Plus if we consider the dodo bird verdict “The assertion that different bona fide therapies are about equivalent in their efficacy and effectiveness.” (Cooper, 2008, p. 52) it potentially provides insight into why this occurs. It is easy to imagine a world where a lot of therapists naturally possess a accepting, understanding and genuine way of being; the core conditions do not necessarily need to be taught. So it could be argued that the core conditions could manifest as different therapeutic characteristics in a similar way to how primary colours create different colours. Implying that the facilitation of creative and expressive therapy is not to imply the core conditions as insufficient because it could be argued this method of work is the manifestation of a blend of the core conditions; specifically empathy and intellectual resonance - an element of self resonance (Mearns, Thorne and Mcleod, 2013).

 

Yet it is not the core conditions that necessarily facilitates therapeutic development, research demonstrates that it is actually the client that is responsible for therapeutic change.

 

For many counsellors and psychotherapists, a basic assumption may be that it is what they do – or the conditions they create – that is the principal factor in determining therapeutic change. However, the empirical research suggests something very different: that it is actually the other member of the therapeutic dyad, the client, who is primarily responsible for change in therapy. (Cooper, 2008, p.60)

 

Which is a discovery that supports the person-centred philosophy of the client being the expert of their own world and therefor the agent for change (Rogers, 1967; Kirschenbaum and Henderson, 1990; Merry, 2002; Tolan, 2017). It also demonstrates how complex person-centred practice can be; a practitioner cannot simply rely on theory to guide their practice, they must be responsive to their clients’ needs. Responsiveness being a therapeutic characteristic that correlates with positive therapeutic outcome (Wampold and Norcoross, 2011). So it is not like the practitioner is an artist and the client is simply a canvass to which they apply their art – from a person-centred perspective all individuals are simultaneously artists and canvasses. The artist within is symbolised as the actualising tendency which is a creative force which manifests as an individual’s will. It is not necessarily a positive or moralistic force as it is “. . . ubiquitous and constant. It is the motivation for all activity of the person, under all circumstances, favourable or unfavourable for the specific person.” (Bozarth, 1998, p. 29). The canvass within could be understood as the self-concept, which can be moulded by the conditions of worth we are subjected to throughout our life; the expectations of the society that surrounds us. This understanding is what makes person-centred theory revolutionary. We are not in the business of painting on the canvasses our clients present, we want to release the artist within them; potentially empowering our clients to paint on the canvass that society presents. Person-centred theory is not just about healing, it can inspire empowerment.

 

The problem with delineating the person-centred therapeutic process is that it is not only complex, but it is also relative to each individuals’ needs, so it is impossible to paint the full picture because the picture is forever transforming and developing since the intersubjective realties that are created are as unique as the subjective worlds that are phenomenologically perceiving them.

 

These complexities are compounded by theoretical development. For example, the theory around the self-concept has been developed to a point of pluralisation; it is theorised we do not have a singular self-concept but multiple concepts of self; symbolised as configurations of self (Mearns, Thorne and Mcleod, 2013; Lago and Charura, 2016). As a practitioner myself I feel resistance to this symbolisation because to me it comes across as somewhat mechanical, preferring to term this theoretical development as spectrum-of-self, which feels more respectful to the fluidity of life and human experience. So it could be said that people’s different configurations, or aspects of their spectrum-of-self, come to the surface when they feel like certain aspects of their sense of self helps them feel like they belong,

 

The person takes their social, relational context into consideration. As the actualising tendency prompts a response, part of that response is to inspire a counterbalancing vector representing the social rather than the purely individual concerns for growth.(Mearns, Thorne and Mcleod, 2013, p .24).

 

So perhaps person-centred practice is best understood as a practitioner trying to facilitate a relationship where the client does not feel a need to manifest any specific aspects of their spectrum-of-self to feel like they belong; the potential power of the core conditions. Potentially allowing the client to get in touch with the centre point of their spectrum-of-self, their true self; traditionally termed the organismic self (Kirschenbaum and Henderson, 1990; Merry, 2002). Yet what if a client is unable to achieve this? Rogers’ 1959 theory gives us insight into how our need for positive regard can inspire us to become incongruent; denying or distorting aspects of experience to maintain the self-concept that society has helped us to develop – the filter through which aspects of our spectrum-of-self manifest. If a client’s self-concept is distorting or denying aspects of organismic experiencing it is unlikely the therapeutic endeavour is going to be able to reach the essence of an individual’s being. Therefore, potentially facilitating the process of incongruent actualisation (Merry, 2002). Or perhaps the client is consciously defending this core aspect to their sense of self because of the conditions of worth they have been subjected to, causing deep shame about these aspects. A generalised view of society suggests incongruent behaviour is valued higher than authenticity; think of what it means to be a professional, or an adult. Logic and reason are valued higher than emotion and creativity; being emotional, sensitive or vulnerable can be considered a weakness in many social environments. No further generalisations will be made, because those who paint with a broad stroke miss the fine art found within life. The point being made is that although person-centred therapy aims to work with the essence of someone’s being, the socialisation that many individuals go through creates powerful defences within the self-concept that shield this essence. A society that symbolises sensitivity, vulnerability and emotive disclosure as weak is likely to create individuals who experience shame about these aspects of human experiencing, therefor self-concepts may distort experiencing to avoid negative experiencing. Think of how some men are at ease with expressing anger, but struggle to display their sadness; evidence of incongruence. Then we take the fact that these deeper aspects of human experiencing may be defended by self-concepts that have perhaps also received the message that incongruence is a valued aspect to being human, meaning even if they begin to become more congruent internally, they may not feel able to express it. Then the valuing of logic and reason might encourage people to explain their reasoning and the content that surrounds their process rather than genuinely expressing from this deeper aspect of self. It is hoped that the presence of the therapist, and the co-created relationship supported by the manifestation of the core attitudes will allow a client to get in touch with and express from these deeper aspects of self; perhaps reengaging them with their true essence of being. But what if the client’s defences are too strong and traditional talking therapy is not appearing effective? When traditional talking therapy is not appearing effective the person-centred therapist may feel it is appropriate to introduce creative therapy. It is worth noting that talking therapy is a reductive term to the process of person-centred therapy – especially when it is perceived through the perspective of an experiential practitioner. Person-centred therapy is about the creation of an intersubjective reality through human expression; not just verbalisations. Perhaps it could be argued that the words we use can at times be filtered through our self-concepts’ to protect the deeper aspects of ourselves that we do not want exposed. Whilst perhaps other forms of human expression are not subjected to this filtering process, potentially signalling why experiential work can be so effective; the therapist is noticing things that are perhaps either outside the client’s awareness, or aspects of experience the client is trying to hide. This supports the artistic and creative nature of person-centred therapy. No matter how enhanced a practitioners reflexive skills are, in real-time scenarios there is not enough time to logically process all the different potentialities, therefore, leaving practitioners to follow their hearts; the home of creative expression.

 

As a practitioner I am hesitant about utilising creative therapy. Mainly due to my experiences of being a client when this way of work is utilised. Through sand tray work I surprisingly discovered that I never really felt loved by my mother, and as a result I do not feel particularly safe within personal relationships – I have developed insecure attachment issues. Now this awareness surprised me, I had previously been incongruently symbolising my tendency to withdraw from social situations as being somebody who appreciates solitude, which is just a half truth. I do not feel welcome in many social situations and deep within me I possess a neediness to feel welcomed and loved, and there also resides a deep fear of feeling unwanted – therefore I withdraw to escape the anxiety that these aspects of my spectrum-of-self present. This discovery was facilitated by creative work and it was a discovery that hit me hard; leading to deep anxiety, depression and fresh resentment. And perhaps the potential to release the unknown is why research on art therapy could be symbolised as ambivalent

 

While a small number of case studies and pre- to post- studies indicate that participation in art therapy is associated with significant improvements on a range of measures for both adults and children, controlled studies – both randomised and non-randomised – give a more mixed picture. (Cooper, 2008, p. 170)

 

Now my personal discovery has not inspired much personal development, but has provided me with deeper understanding of myself. Now perhaps this deepened understanding will eventually manifest in personality or behaviour change, “ . . . the curious paradox is that when I accept myself as I am, then I change.” (Rogers, 1967, p. 17) Yet this experience has led me to conclude that perhaps, within certain contexts, a little bit of incongruence can go a long way. Making me wary of this way of work because of the surprising power it appears to have.

 

So creative therapy is about utilising different therapeutic methods that facilitate creative forms of human expression; art work, sand tray work and chair work are just some examples. It could be implied that the core conditions help create an appropriate environment to introduce this type of work, as long as you have the relevant materials that is, or it could be argued that this type of work is an extended manifestation of the core conditions. But it is important to be aware that without a safe and established relationship the client may not be able to genuinely engage with this process. This is concluded from my experience of attempting to facilitate some sand tray work after being advised to by my supervisor. Which is indicative of abandoning the core conditions; to follow advice is to not be present in the real-time development of a relationship, and to not be present is to deny the core conditions their foundation (Cooper et al, 2013). I felt it would have been appropriate to refer this client to another therapist within our service, as she had been abused and victimised by the males within her immediate family. Indicating that the self-resonance she was experiencing within my presence, as a male of a similar age to her cousin, would likely to have been unhelpful. Yet I submitted to the authority I had given my integrative supervisor and regrettably did not share my thoughts around referring this client on; perhaps due to a fear of being perceived incompetent. I blindly followed her advice. And even though utilising the sand tray can be very powerful it would appear that if a client does not feel safe and secure within a relationship, regardless of whether the core conditions are present or not, they are unlikely going to be able to let go of their self-concept and fully engage with the therapeutic process. I had experienced a resistance with this client throughout our therapeutic alliance, and upon reflection and being somewhat analytical, I would conclude that the self-resonance that my client was potentially experiencing may have brought aspects of her spectrum-of-self that stopped her from being open and authentic with me, blocking her from communicating from her true essence. The sand tray work did not cut straight through her defences because I do not believe she felt safe enough to let go of them, indicating the importance of the development of a strong therapeutic alliance before this type of work is facilitated. Ultimately, I feel I let this client down and I believe I should have trusted my own internal locus of evaluation over the advice of my supervisor.

 

Chair work is slightly different to art and sand tray work in the fact that it still utilises verbalisation as its main form of human expression. But it is creative in the fact that it can facilitate an encounter of different aspects of the client’s spectrum-of-self. One of my client’s had experienced ongoing childhood sexual abuse and was deeply angry at her younger self because she had enjoyed, what she believed at the time, to be special attention. She was very angry and deeply ashamed. Although I did not have an empty chair to facilitate chair work I did have access to some stuffed toys which I used instead. The important aspect about utilising creative therapy is not to insist on its utilisation, but to invite the client to experience this method of work. This way a respect for the client’s autonomy is maintained. Yet if the client accepts the invitation then the therapist has a responsibility to become somewhat directive of the therapeutic process. Which can create tension for practitioners because the origin of person-centred therapy was the non-directive approach (Kirschenbaum and Henderson, 1990); meaning many practitioners feel that to remain person-centred they are to remain non-directive which is not necessarily true, as Mearns implies non-directivity could be considered a fallacy (1980). As long as the client is free to refuse continuation at any point then I would argue this practice as person-centred. Perhaps being prepared to be non-directive is a more realistic characteristic of person-centred therapy. Anyway, I invited the client to take part in some creative work by utilising a stuffed toy as her younger-self. An invitation she initially rejected, but then requested to try out the following session. What followed was a very emotive and powerful session. A lot of anger and shame were expressed when she initially spoke to her younger-self, but when I asked her to speak to the teddy as her younger-self, requesting her to symbolise the teddy as the angry part of herself, a lot of sadness and confusion was expressed. By the time we switched the roles of client and teddy again a lot of the anger had evaporated, and forgiveness had been discovered. The process had facilitated inner empathy. Throughout this session my style of work had remained very classical; as the client’s relationship with her inner self felt more important than the therapeutic contact. This session was very powerful and it appeared to bring my client some much needed peace; there was an explicit difference in how my client presented after that session; there was a lot more acceptance. This kind of work could be symbolised as process direction on steroids. This time my creative endeavour had been effective.

 

My brief experience with art therapy, working with a peer in class, also appeared effective. I shall remain brief out of respect to my friend’s right to confidentiality. So all I can say it was like she had manifested a felt-sense onto the paper in front of her and then began to apply meaning to it as she started to make sense of her creation. “A felt sense lets one discover that one is not the felt sense. When one has a felt sense, one becomes more deeply oneself.” (Gendlin, 1998, p. 21) Again I worked very classically, although I was also making meaning out of her externalised felt-sense. This is because my peer was in deep process and it felt unethical to become collaborative with this deep exploration of self; it felt like it would be invasive, unneeded and possibly damaging. My peer symbolised her experience at the end as surprising and it deeply moved her. This mirrored my experience of being a client, except her experience was one of a more positive nature. Creative work is like allowing the essence of somebody’s inner-being communicate an message to the more aware and active part of the spectrum-of-self; which is strikingly similar to what traditional person-centred therapy hopes to achieve.

 

So person-centred therapy could be argued to be creative within its very nature. Yet therapeutic development is more dependent on client variables. It has been theorised that a human-being possesses a spectrum-of-self within. It must be stated that this symbolisation may still be an over-simplification due to all the various variables that have not been explored – but it is still in line with person-centred theory. Now from a traditional perspective the core conditions are theorised to facilitate a person getting back in touch with this inner essence of self, found at the core of this spectrum; the organismic-self. Yet due to conditions of worth and the socialisation process of human development strong defences may be utilised to protect this essence, either distorting or denying experience, or denying or distorting human expression. Creative therapy can potentially cut straight through these defences as long as a strong therapeutic alliance has formed and therefore powerful discoveries can potentially be made. To remain person-centred the client has to accept an invitation to participate with this method of practice and their right to autonomy must be maintained. Although in practice these therapies may look different, their intentions remain the same. Person-centred therapy is creative therapy, and creative therapy can be person-centred. To utilise creative interventions could indicate a lack of faith of the sufficiency of the core conditions; but it could also be argued as an extended manifestation of them as well. I believe the core conditions to be potentially limitless.

 

References

Barrett-Lennard, G.T. (1998) Carl Rogers’ helping system: Journey and substance. Thousand Oaks, CA: SAGE Publications.

Bozarth, J (1998). Person-Centred Therapy: A Revolutionary Paradigm. Ross-On-Wye: PCCS Books.

Cooper, M. (2008) Essential research findings in counselling and psychotherapy: The facts are friendly. Los Angeles: SAGE Publications.

Cooper, M. O’Hara, M. Schmid, P.F. and Bohart, A.C. (2013) The handbook of person-centred psychotherapy and counselling. 2nd edn. New York: Palgrave Macmillan.

Gendlin, E.T. (1998) Focusing-oriented psychotheraphy: A manual of the experiental method. New York: Guilford Publications.

Kirschenbaum, H. and Henderson, V.L. (1990). The Carl Rogers Reader. London: Constable and Robinson.

Lietaer, G. (1993) Authenticity, congruence and transparency. Available at: http://www.elementsuk.com/libraryofarticles/authenticity.pdf (Accessed: 21 May 2017).

Lago, C. and Charura, D. (2016). The person Centred Counselling and psychotherapy handbook: Origins, developments and contemporary practice. United Kingdom: Open University Press.

Mearns, D. (1980). The Person-Centred Approach to Therapy. Available: http://www.elementsuk.com/libraryofarticles/thepcato.pdf. Last accessed 10/05/17

Mearns, D and Thorne, B (2000). Person-Centred Therapy Today. London: Sage Publications Ltd

Mearns, D., Thorne, B. and McLeod, J. (2013). Person-centred counselling in action. 4th ed. London: SAGE Publications

Merry, T. (2002) Learning and being in Person-Centred Counselling. 2nd edn. London, United Kingdom: PCCS Books.

Norcross, C. J. and Wampold, B. E. (2011). Evidence-Based Therapy Relationships: Research Conclusions and Clinical Practices. Psychotherapy. 48 (1), 98 - 102

Rogers, C. (1957). The Necessary and Sufficient Conditions of Therapeutic Personality Change. Available: https://app.shoreline.edu/dchris/psych236/Documents/Rogers.pdf. Last accessed 06/06/2017

Rogers, C (1967). A Therapist's View of Psychotherapy: On Becoming A Person. London: Constable & Company

Tolan, J (2017). Skills in Person-Centred Counselling and Psychotherapy. 3rd ed. London: Sage Publications Ltd.

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