Recommended Principles and Practices for the Provision of Humanistic Psychosocial Services
Recommended Principles and Practices for the Provision of Humanistic Psychosocial Services:
Alternative to Mandated Practice and Treatment Guidelines
Task Force for the Development of Practice Recommendations For
the Provision of Humanistic Psychosocial Services
This document was formulated by a group of psychologists concerned with the increasing medicalization of and press for homogeneity in psychotherapy. The authors clearly differentiate the approach represented by those who are pressing for narrowly defined "evidence-based treatment" and the approach taken by humanistic psychologists. The members of the Task Force that produced this document were Arthur C. Bohart, Chair, Maureen M. O'Hara, Co-Chair, Larry M. Leitner, Fred Wertz, E. Mark Stern, Kirk Schneider, Ilene Serlin, and Tom Greening. An earlier version of these recommended principles was published in The Humanistic Psychologist, Volume 24, Spring 1997, pp. 64-107. They are reprinted here with permission.
An initial draft of the major portion of this document was approved by the Board of Division 32 and subsequently published in The Humanistic Psychologist, 25(1), Spring, 1997, as “Guidelines for the Provision of Humanistic Psychosocial Services." This was done to solicit feedback from Division 32 members. The additional draft section on Training and Ethics was published in The Humanistic Psychologist, 25(3), Autumn, 1997, also to solicit feedback. The final version was approved by the Division 32 Board in 1999. The document was then submitted to the American Psychological Association to undergo its guidelines review process. Initial steps of this process were successfully completed, including review by APA’s Legal Counsel and submission to all APA divisions for feedback. Ultimately, however, because of APA’s specific definitions of what constitutes guidelines, it was decided by the Division 32 Board in 2001 to reconstrue the document as “Recommended Principles and Practices For The Provision of Humanistic Psychosocial Services: Alternative To Mandated Practice and Treatment Guidelines.” Minor changes in wording were mandated due to this alteration, and have now been completed, along with minor updating of research citations.
In order to better provide services to people, The Division of Humanistic Psychology of the American Psychological Association has prepared the following recommendations concerning the principles and practices of humanistic psychosocial services. This is necessary in a day when accountability of service-providers is a major issue, and when some attempts to provide guidelines for the provision of therapeutic services have threatened to restrict consumers' freedom of choice. Under these conditions, it is important that humanistic psychologists articulate the principles under which they operate for the responsible and helpful provision of services.
Humanistic psychologists form their own community of practice and hold their own distinctive views of human nature, of science, of research methodology, and of psychotherapy. Humanistic psychotherapy deals with psychological dysfunction in the broad context of clients' engagements in life and ways of being in the world. Humanistic psychologists are oriented towards promoting the psychological development and growth of individuals, families, and communities through the support of their own creative and self-initiated efforts. Psychological development includes the development of greater capacities for self-understanding, understanding of others, and understanding of relationships; clarification and development of values and life goals; development of a greater capacity for deep experiencing; the strengthening of relational bonds; the promotion of an environment of mutual care and empathy; development of a greater sense of personal freedom and choice while respecting rights and needs of others as well as the limits imposed by reality; and the strengthening of individual, relational, and group agency. Humanistic interests are likely to include phenomena such as the aspirations of whole persons, their goals, their desires, their fears, their potential for growth, their higher selves, and qualities such as empathy, congruence, authenticity, presence, and intimacy. Discontinuities in life and in experience, tragedy, and pain, are taken seriously as often reflecting basic issues concerning the nature of the self, the nature of existence, and the nature of one's engagement in the world, rather than being seen as pathogens to be eliminated. Since humanists hold issues of human value as fundamental, the provision of humanistic services is unavoidably an issue of human value.
Humanistic practices are holistic and are based in a view of the therapeutic process as a dialogical activity, which occurs through person-to-person conversations and through intersubjective symbolic activities. Humanistic services begin from the assumption of a client whose choice to seek therapy is personal. This entails a view of the client as an agent, who must be engaged in the creation and development of all therapeutic processes, not only as a matter of theoretical truth and clinical efficacy, but also of ethical integrity and coherence. Therefore humanists reject the model of the practitioner as the expert who decides for the patient what the appropriate treatment is. Humanistic practitioners recognize that their job is to place their expertise at the service of their clients and to establish a collaborative dialogical relationship with them. The joint project of client and psychotherapist is to work towards individualized goals that are framed in the clients' world view and understandings of their own aspirations rather than on normative diagnostic categories. Humanists believe that the methods used in providing services must reflect the basic value of promoting the agency and empowerment of individuals and groups.
Humanists, in agreement with many feminists, family-systems theorists, and ethno-cultural therapists, believe that relational phenomena are fundamental and not reducible to the sum of individualities. Humanists recognize both the particular and integral aspects of consciousness, and that human beings are both unique and yet live in larger relational contexts which have their own emergent properties and integrity. Therefore, when humans enter into relationships with other humans to provide help and assistance, they of necessity become part of larger relational entities which must be treated as having their own properties that go beyond the sum of the parts. Such a position makes any therapeutic stance based in a view in which an individual or institution makes unilateral decisions about the life of another person both impractical and unethical. In this document we will elaborate on these basic ideas and present a humanistic model of praxis, science, research methodology, diagnosis, and ethics, for the purpose of providing guidelines for the provision of humanistic services.
It is important to recognize that this document constitutes an alternative to practice and treatment “guidelines.” The term “guidelines” refers to pronouncements that support or recommend, but do not mandate, specific approaches or actions. This document, as with guidelines, is intended to provide recommendations of principles for practice that are aspirational in intent. However, in contrast to guidelines, which typically focus on or recommend specific approaches or actions, these recommendations focus on the use of guiding principles, consistent with humanistic philosophy and practice. This document is intended to facilitate and assist the provision of services, but it is not intended to be mandatory, exhaustive, or definitive and may not be applicable to every situation. It should not be construed as definitive and is not intended to take precedence over the judgment of psychologists.
Introduction and Rationale
In these days of public accountability—a movement which humanistic psychologists who offer services to the public support—various groups are producing documents specifying guidelines for appropriate practice. In this document humanistic psychologists present their recommendations of principles for effective practice. There are three reasons why we are doing this. First, we want to articulate the principles upon which our community of practice is based, so that both practitioners and consumers have criteria with which to judge if services are being provided in a manner congruent with humanistic principles. Second, we believe that the humanistic paradigm represents an important perspective on the nature of human beings and human change, and we wish to articulate its general principles and concepts for all who are interested. Third, other groups and individuals have articulated principles which threaten to disenfranchise humanistic as well as many other forms of psychological practice. We believe it is important to make a positive statement of our principles in terms of why the guidelines of these other groups do not provide appropriate criteria for our practice.
The development of guidelines for the provision of both medical and psychological services is a recent national and international trend. These guidelines are based on the developers' interpretation and assessment of available evidence, and that in turn is affected by the developers' biases concerning their own preferred modes of treatment and their preferred ways for conducting empirical research. The recent guidelines for the treatment of depression (Depression Guideline Panel, 1993), for instance, issued by a governmental agency operating within a medical model frame of reference, privileges medication over psychotherapy [despite compelling evidence to the contrary (Munoz, Hollon, McGrath, Rehm, & VandenBos, 1994)], and conceives of depression as a chronic “illness.”
The development of guidelines is part of an international movement towards "evidence-based" practice (Rowland & Goss, 2000). However there are many different models of how to base practice on evidence. For instance, one approach is to base practice upon evidence for various principles of change (Bohart, 2000; Goldfried & Wolfe, 1996; Rowland & Goss, 2000). This is the strategy that has been followed for developing the recommendations in this document. Another approach has been the "empirically supported treatments" movement (e.g. Chambless & Hollon, 1998), more popular in the United States than in other countries (Rowland & Goss, 2000).
The empirically supported treatments movement focuses on the degree of evidence for specific treatments for specific disorders. While different authors writing from this approach have come up with slightly different criteria, overall there is a good deal of consistency, and these criteria are of particular relevance to the concerns of humanistic psychologists. These criteria are based upon implicit assumptions about the nature of psychotherapy and favor approaches which a) adopt a medical model perspective on psychological dysfunction and its remediation, b) are focused on symptom removal, and c) are technological in nature. Although other approaches are not explicitly ruled out, the criteria do not fit well with psychotherapies that are discovery-oriented, holistic, and relational. These documents also privilege particular natural science research methods, and marginalize other methods more compatible with the study of psychotherapies that share a focus on the particular individual, subjective and multiple realities, and contextuality and relationship. Because there exists a potential for these documents to be used to dictate what is appropriate psychotherapy practice for everyone, it is necessary for us to articulate our alternative vision of the human being, of psychological problems, and of psychotherapy, as well as of research methodology and the general relationship between science and practice. For us the issue is ultimately one of freedom of choice for consumers, who must be allowed to choose the psychotherapy modality which best fits their needs, rather than have that choice made for them by a particular group of professionals.
Most versions of “empirically supported treatments” (EST) guidelines are based on traditional natural science criteria, modified to appeal to business and governmental agencies which think in medical model terms. The criteria rank the randomized controlled clinical trial (RCT) at the top of a purported validity hierarchy of methods for evaluating psychotherapy. In addition, to be considered by supporters of the EST movement as an “empirically supported treatment” a given therapy must have been validated in studies in which the therapy is manualized, and where the therapy is studied as a treatment for a particular problem or disorder. These guidelines do not require that the disorder be specified in DSM terms. However, specific symptom-focused approaches, highly compatible with DSM are favored. Such criteria are biased towards certain types of therapies, and lists of empirically supported treatments have tended to exclude therapies which emphasize personal discovery and relationship, including many psychodynamic, feminist, constructivist, narrative, and family systems approaches, as well as humanistic therapies. This is despite substantial empirical support for various humanistic practices and assumptions. For instance, EST criteria dismiss years of psychotherapy research that support humanistic therapies and assumptions because many of the studies did not include manualization of the therapy being studied and because the therapy was not targeted to treat a specific disorder or problem. Proponents of ESTs also wish to see their paradigm become the dominant one for guiding both psychotherapy research and training (e.g., Lampropoulos, 2000).
The logic of the randomized controlled clinical trial best fits psychotherapies which can be structured so as to operate in a manner analogous to medications. That is, they can easily be manualized as a specific set of procedures or strategies designed to treat a particular disorder, for instance, a therapy which is described as a specific set of procedures and strategies for “treating depression.” In such a case it is possible to randomly assign depressed people to a treatment and to a control group, apply the procedures to the treatment group, and measure to see if depression is alleviated. If so, then it can be said that the procedures “caused” the alleviation of the depression. The logic of the randomized controlled clinical trial purports to establish linear, efficient causal relationships between treatment application and outcome. However this logic does not fit with therapies which are not conceived of as the application of specific procedures to alleviate specific disorders—therapies where healing ultimately results from personal discovery and where the primary modality is that of a flexible, creative, and dialogical relationship between therapist and client. Further, this model of science and research, limited to establishing causal relationships, is unable to scientifically address important questions such as the personal meaning and value of even those therapies it does fit. Thus, while RCTs are one valuable way of investigating psychotherapy, there are many aspects of the human experience of psychological life that cannot be addressed by such methods. Thus RCTs themselves must be treated as only one among many methods for investigating psychotherapy, rather than being held up as the definitive method.
Similarly, therapeutic efficacy is defined in a manner analogous to a medical model in which the goal is cure of a disease. That is, therapy can be said to be effective if it leads to the remedy for a particular targeted problem or disorder. However there are many other ways psychotherapies can be effective. Many approaches to psychotherapy do not hold that effectiveness in psychotherapy is homologous to effectiveness of a drug. For one thing, a therapy could be said to be efficacious if it provides a certain kind of opportunity or experience that clients seek. Clients might take advantage of this opportunity or experience to make a variety of personal changes, none of which are connected in a linear, mechanistic way with what the therapists do. Humanistic psychotherapists, with their emphasis on the collaborative nature of the relationship with their clients, do not see effectiveness in terms of a method's ability to operate on clients and change them, but rather in terms of the kinds of conditions therapists provide which allow clients to take their pain seriously, explore their lives, and find more meaningful ways of engaging in their existence. The issue for the humanistic psychologist, as well as for therapists of many other persuasions, is how best to provide guidance, support, and resources which are useful to the client.
In contrast to the medical-model view of psychotherapy implied by EST criteria, humanistic models begin with the goals identified by the therapist-client team when evaluating whether a given therapeutic approach is beneficial or not. The question “Is a given technique effective?” becomes recast as “does the professional provide the services that the team has agreed could be helpful?” This question puts the evaluative emphasis on specific practitioners following specific principles in specific context and asks “under these specific conditions, do specific clients move towards their own, self-defined goals?” One can then ask if the resources provided are helpful and useful—in other words effective—for this particular client, under these particular circumstances. Therefore, humanistic therapists reject the empirically supported treatments approach to identifying effective psychotherapy, even though several humanistic therapies have now been researched and supported from within the empirically supported treatments paradigm (Elliott, Greenberg, & Lietaer, in press). Although we shall cite empirical evidence supporting humanistic practice based on natural science procedures, such externally validated studies across multiple practitioners and multiple clients become less relevant as evaluation criteria shift to specific instances and away from generalization.
This means that fundamentally different models of training are required for the preparation of competent humanistic clinicians than those implied by criteria for empirically supported treatments. Training becomes less of a matter of acquisition of technological skills to be applied consistently and with mastery, and more a matter of the development of: perceptual and interpersonal sensitivity; self-awareness; higher order mental capacities such as the ability to take multiple perspectives on issues and problems and the ability to engage in more complex thinking about values; the skill of relating general research findings and scholarly discourse to specific persons in naturally occurring contexts; and other non-formalizable complex skills for facilitating human growth and liberating client creativity. This emphasis on the therapist's development of his or her own mental and relational capacities follows from the humanistic position that therapists must be able to entertain and really appreciate multiple perspectives on reality, and that it is clients who are ultimately the experts on their own lives, their own life circumstances, and the contextualized complexities interwoven around their problems. Therapists must be able to believe that it is only clients who can ultimately know what are the appropriate ways for them to approach and resolve their problems, within the contexts of their life structures, life histories, and the constraints of society. This means that the therapist's sensitive and flexible ability to dialogue with clients becomes the ultimate therapeutic modality.
In the context of the current struggle to define “evidence-based” practice (e.g., Rowland & Goss, 2000), it thus becomes necessary for Humanistic Psychologists to either subscribe to the research, training, and treatment protocols endorsed by others, or to establish their own criteria for “effectiveness” to which professionals, users of services and educators can refer as a means of discriminating good practice from the inadequate. In order to assure that an open stance towards psychological science be maintained, and to insure that everyone is not held to the same way of understanding human psychological life, which we believe will result both in stifling free enquiry and in limiting the choice of services available to the public, a humanistic “template” is necessary. For this reason, in this document, we a) elucidate the conceptual foundations of humanistic practice, b) elucidate the logic underlying research support for humanistic practice, and c) present our own recommended principles for practice. Further, we take the stance that any genuinely scientific endeavor—one grounded in the search for truth—of necessity must remain open to a variety of methods (i.e., different ways of approaching truth).
The final rationale for the creation of a humanistic set of recommended principles and practices comes from the need to counteract the paradigmatic biases built into other approaches. The evaluation criteria of these other approaches discredit research performed according to research protocols at odds with their own mechanistic positivism, and thus disenfranchise a whole body of research performed both within and outside of the humanistic psychology community, which already establishes the fact that humanistic psychotherapies are both effective and well liked by the therapy-going public. These humanistic recommendations will argue that this disenfranchisement is unwarranted based upon the facts. Furthermore, these recommendations will support the position of the humanistic approach by reference to studies performed using both positive science protocols and post-positive protocols.
Philosophy, World View, and Praxis
In order to provide the ground and rationale for our guidelines, we present basic aspects of the humanistic perspective on epistemology, on the nature of the person, on psychological dysfunction, and on psychotherapy. There are many humanistic theories, some of which include: person-centered, gestalt, existential, transpersonal, constructivism, archetypal psychology, experiential therapies, logotherapy, general semantics, the expressive therapies (art, dance, music, poetry), integrity therapy, self psychology, radical psychotherapy, interpersonal and relational theory, meditative psychotherapy, intensive journal workshops, psychodrama, some forms of bioenergetic therapy, and many others. We cannot extract a universal set of principles that all humanistic perspectives would agree on, but we believe that the principles we present below represent the views shared by most.
The humanistic world view is not a mechanistic one, but rather relies on a nonlinear metaphysics and postmodern constructivistic epistemology. We hold that the realities people live in are always constructed to some extent, out of their cultural experiences, and out of their personal histories, values, and perspectives. As such there are many viable ways of living life. Humanists value diversity in perspectives on reality, and therefore believe that the ultimate goal of therapy is to help each individual, within the context of his or her relationships and culture, find the most satisfying personal and relational life paths. Humans are whole persons in context and therapeutic solutions must fundamentally be grounded in their life contexts. This means they must perforce be individualized, developed to meet the individual's particular life context, and cannot be chosen as treatments for decontextualized disorders.
Nature of the Person
Humanistic psychology derives from trends in Renaissance, Post-Enlightenment Romantic, and twentieth century existential thinking, and addresses the issue: what are the distinctive features of being human? Our provisional answer to this question is that humans are self-aware, capable of choice or freedom, and capable of functioning in a whole or organismic manner. Humans are also delimited (though not defined) by their genes, physical constitution, culture, and accidents of fate. Humans are not “part-processes” and do not function in the world like animals or objects. They are more than their physiology, overt behavior, cognition, instincts, or even interpersonal relationships or culture, although they are each of those also. In addition, many humanists believe that human beings have a sense of a fundamental connection with life, with being, and with existence (Schneider & May, 1995). In this regard, some humanists take seriously a transcendent or spiritual side to human existence. We further hold the following about human beings:
1. Persons are irreducible to the sum of their parts. While we recognize the usefulness of such constructs as “ids,” “egos,” “schemas,” “object representations,” and “conditioned habits,” overall we focus on the whole person who is choosing, setting goals, pursuing meaning, establishing and living in relationships, and creating.
2. It is nonsensical to consider human beings separate from their organismic bodies. Emotions and experience are an intrinsic part of being human, and the body and the emotional life are not “lower” than rationality. Conversely, rationality is most fully rational when joined with the body and with emotion. Humans are also capable of deeper, nonrational ways of knowing: intuition, a sense of knowing by being joined with others, and knowing through deep experiencing. Humans are more than their consciousness, but what is nonconscious is not necessarily irrational and primitive.
3. Humans also cannot be separated from their relationships and their worlds. Humans-in-relationships form larger units that have their own integrity and existence. Humans are “thrown” into a world where they are inevitably influenced by their time and place—their culture and their surroundings. Personhood is woven out of the individual's embeddedness in time, place, and relationship.
4. Relationships are an intrinsic part of being human, and humans turn to one another for comfort and a sense of meaning when things are going badly. Relationships can involve a real “meeting of persons.” Such a meeting of persons is more than the interchange of operant behaviors designed to bring reinforcement from one another. Humanists take seriously the idea of direct psychological contact and mutuality between two or more persons.
5. Dialogue and communication are essential parts of humanness. Dialogue and communication are among the major means through which selves come to know themselves and to develop and grow, and through which selves develop in relation to others. Dialogue is a mutual process and involves a genuine interchange of ideas.
6. Humans are creative, and can evolve towards more complex and sophisticated ways of conceiving of and experiencing themselves, their relationships, and their world. More complex and sophisticated ways of conceiving of and experiencing self and world can lead to greater empathy for others, a greater capacity to sustain relationships, and greater problem-solving ability.
7. Humans are valuing beings and have a potential for developing and living according to deeply held and abiding values.
8. Humans inhabit the past, present, and future. The past is a dynamic past, a well of experiences influencing present reality and which, even when involving pain and suffering, can be transformed into resources to deepen and enrich the further life path. Humans take action in the dynamic present, but they live towards a future. The future is the horizon of their possibilities.
9. Humans are meaning-makers. Meaning is a product of individuals, communities, and persons-in-interaction. What constitutes a meaningful life is chosen by individuals embedded in communities and in relationships.
10. Humans are agents. This means that they are ultimately the sources and originators of their own actions. They are able to initiate action, make choices, set goals, and chart life courses.
11. Humans as individuals are ultimately responsible for their own individual choice. Individuals must make choices which take both their own individual needs and wishes into account, and those of the people around them.
Different humanistic theories posit different views of psychological dysfunction. What most share in common is the idea that psychological problems arise from the whole person's manner of relating to self and/or to world. Problems are not considered to be solely a product of abstract dysfunctional internal structures such as egos or schemas, nor of isolated conditioned habits and responses, nor of biology. Rather, they arise from the whole person's attempt to adapt and cope with demands made upon the self by the world, biological constraints, traumatic experiences the self has encountered, constrictive and/or oppressive political structures or environments, relationship blocks and disruptions, rigid rules and social norms learned from others, and the self's own anxiety generated by its encounter with the fundamental uncertainty of life. Problematic behavior can be an expression, albeit a counterproductive one, of individuals' desires to grow and become more functional. Psychological problems come into being at the contact boundary between the person and the world; they are not entities in persons. Problems are things individuals have, not things that constitute individuals. Problems cannot be defined independent of a) the client's own personal goals and values, and/or b) the interface of the client's behaviors with the viewpoint and behavior of others (cultural norms, values of one's reference group, or significant others). Problems do not have an existence independent of defining agents (Mahrer, 1996). Problems are inherently valuational, and may involve intrinsically moral components.
Humanistic therapies generally are seen as providing opportunities for self-confrontation, personal exploration, and growth as the means by which individuals confront their suffering, their limits, and their distress. As such these therapies do not typically provide specific treatment packages for specific disorders. In fact, “disorder” is not usually a meaningful category for defining the aim of a humanistic therapy. Rather, humanistic therapies aim to facilitate more general human capacities for being in the world as a way of helping individuals confront and cope with their problems in living. As a result humanists tailor their approaches to individuals not on the basis of the individual's disorder, but on the basis of the individual as a unique person. Work done with one person presenting as depressed might be more similar to work with a person labeled as schizophrenic than to that done with another person presenting as depressed. Because all humans think, experience, value, have aspirations and wishes, engage themselves in life, and make choices, the kinds of experiences humanistic therapists provide could be useful, regardless of an individual's diagnosis.
Psychological problems, or problems in living, are ultimately resolved by helping individuals develop more complex, integrative, balanced, honest, and courageous ways of living, i.e. through psychological growth. Psychological growth consists of creating more deep and complex integrative modes of relating to self and to others, and of new stances of meaning. The goal is not primarily to remedy dysfunction, although humanistic therapists acknowledge problematic behavior and experience and help clients stay with it and learn from it. At times humanistic psychologists may even use symptom-focused procedures to help alleviate problem behaviors and experience, but this is done as part of the larger context of exploring broad personal issues and problems of meaning.
Problems in living are often not isolated entities in themselves to simply be removed. As individuals confront issues concerning their basic values and engagement in the world, they will also confront issues relating to their problems. In some cases problems in living can be modified by focusing on the enhancement of people's resources and the fulfillment of their potential, without therapy even addressing the issue of the problem behaviors and experience. As an example, a person with a physical problem, such as cancer or paralysis, can still find ways to live a productive life. Likewise, even if something that might be conceived of as a psychological “disorder” has a biochemical component individuals can learn from the experience and incorporate it into their lives in a functional (or even creative) manner. On the other hand, there are instances where the painful issues associated with a symptom need to be explored, beyond the use of procedures to facilitate symptom removal.
Humanistic therapies also value the following goals: making the development of freedom and wholeness available to clients, to the degree that they can engage in them; enlarging the person's sense of possibility; helping the person become more aware, sensitive, and capable of choice; and increasing life's vitality—creativity, meaning, purpose, and intimacy with self and others. The aim for many humanistic therapies is to help clients attain a greater sense of personal freedom. Freedom is defined as the capacity for choice within the natural and self-imposed limits of living. Yet another goal of humanistic therapies, if clients so wish, may be to help them develop deeper capacities for experiencing in the ways they relate to themselves and the world. Included in this may be the development of transpersonal aspects of the self. Transpersonal aspects may include spiritual aspects, or may be nonspiritual, but still include a deeper relational sense of connection to others, to being, and to life.
Outcome from a humanistic perspective is highly individualized. While recognizing the ever present possibility that people—and this applies equally to therapists and clients—are sometimes self-deceiving, the humanistic psychologist nevertheless accepts that ultimately what is a successful outcome can only be best judged by the consumer.
Processes and procedures
In practice, humanistic psychotherapies are not typically goal-driven in the sense that they set out to specifically achieve a particular set of predefined goals, such as overcoming shyness, learning to communicate better, or feeling less anxious. Some humanistic therapies (e.g., Mahrer's, 1996, experiential therapy) are not goal-driven at all in the sense of trying to achieve particular outcomes, and in that sense are almost purely process and discovery oriented. When goals are decided upon, they are decided upon by the therapist-client team. However goals often change and evolve as the therapy process progresses. In any given therapy encounter it is often not possible to specifically predict in advance what kinds of positive outcomes will ultimately emerge as the relationship evolves and changes. Outcomes are often creative emergents (Kampis, 1991), such as second-order changes (Watzlawick, 1987).
Instead of focusing on specific outcome goals, humanistic therapists typically focus attention on process. In general therapists want to take humans seriously in terms of their own experience, “salve the human spirit,” and help individuals discover how they want to promote their own development, and by so doing, cope with problems in living. In order to do this therapists aim to provide an optimal relational process within which a client can reflect upon the patterns of his or her life, experience him or herself more deeply, access or mobilize his or her own capacity for agency, and experience and explore the formation and function of relational bonds. In this regard the humanistic therapist allows the client to stay close to his or her suffering and to learn from it. However, distress is seen as one aspect of the whole person, and the ultimate focus of the therapy is more on the whole person's engagement with self and with life.
Therapists provide such an optimal relational process first by keeping in mind the humanness of the therapeutic encounter. Both psychological problems and their alleviation are seen as ultimately involving the humanness of the participants. Thus post-traumatic fears are not treated simply as pathogens to be deconditioned or emotionally reprocessed through exposure. Although a humanistic therapist might use such behavioral techniques as exposure, it is always included within the larger human context of the meaning of the experience in terms of a person's values, needs, life directions and ways of being in the world. Similarly, a humanist might use a technique like cognitive restructuring. However what cognitive therapists call dysfunctional cognitions are not viewed by humanistic therapists only as errors in logical computation, but as attempts by individuals to cope with experience and to find a place in the world.
Second, therapists facilitate an optimal context by keeping their attention primarily focused in the moment and on the experience of this unique individual. Sensitive, skilled, and flexible attending to the ongoing emerging process between therapist and client is the sina qua non of humanistic therapy. Therapists sensitively track the experience of the client as the client struggles with issues and experience, track emerging themes, and bring in suggestions, ideas, and techniques when they are relevant to what is happening in the moment. Therapists keep their attention focused more on what is unique about this particular client than on what is common about him or her with respect to others who may share the same presenting complaint or diagnostic category. Therapy therefore consists of an open-ended process oriented towards discovery and meaning-making. The therapist functions as a skilled and disciplined improvisational artist, not as a technician implementing a treatment manual. Therapists may use any of a variety of techniques, such as cognitive restructuring or exploring childhood experiences. However these are suggested only when they fit the needs of this particular individual in this particular moment in the therapy process.
Third, therapists provide an optimal relational process by exercising certain other core skills. Minimally, these include the ability to: a) empathically understand and grasp the world of the client, b) accept, affirm, value, or prize the client, and c) facilitate and participate in co-constructive dialogue with the client. Additionally, most humanistic therapists also try to optimize the relational process by: a) being a real self-in-relation to the client, and b) genuinely engaging in a “meeting of persons” with the client.
Fourth, the therapist believes that clients are the ultimate experts on their own experience. Ultimately it is clients who must decide, within the constraints of their life structure and of society, what changes to make and how to make them. Humanistic therapists hold a basic respect for the personal reality of clients. In addition clients are seen as authentic sources of their own experience. Further, humanistic therapists relate to the client out of a genuinely held egalitarian stance. In such a model, it is paradigmatically incoherent to: a) think of the client and the process of therapy primarily in terms of the “expert therapist's” assessment of the client's “disorder,” and b) approach therapy with a pre-defined “treatment plan” based upon that assessment. Doing so interferes with the therapist’s capacity for tuning into client uniqueness, individuality, strength, and potential.
Fifth, a major therapeutic issue for many clients has to do with their personal theories of living. There often is a philosophical or moral component to therapy, and therapy can be the facilitation of clients confronting certain basic issues and values about being human and being alive. Therapists help clients more meaningfully “restory” their lives to create a deeper sense of personal meaning.
Sixth, therapy for many clients revolves around a basic struggle to achieve both a sense of genuineness and intimacy in relationship to other human beings. The resolution of this struggle cannot be manualized, nor “treated” with a “treatment plan.” Instead, the therapist must be present as another human being and be willing to be a part of that struggle.
Humanistic therapies are thus not based on the medical model. To quote Bohart, O'Hara, and Leitner (1997), “ In contrast to therapy as the mechanical application of a treatment procedure, therapy is a recursive, self-adjusting, creative, interactive intelligent process (Karen Tallman, personal communication, October, 1996), a complex nonlinear dynamic system.” Therapist and client are the two major variables in the approach; rather than treatment and disorder, as is the case for the EST criteria. Dialogue, instead of preset choice and application of technique, is the sina qua non of the process. The process of the therapist and client listening to one another and interacting is primary, with theoretical ideas and techniques used as aids or adjuncts in that process. Techniques and procedures take on their meaning contextually (Butler & Strupp, 1986). Therefore there is no such thing as an invariant procedure uniformly applied across the board to clients who share the same diagnosis. The therapist-client pair working together is the “treatment of choice,” rather than any specific treatment package. As Bohart, O'Hara, and Leitner (1997) note:
A therapist's particular theoretical stance and package of techniques are ways to implement his or her therapeutic interpersonal presence and spontaneity, rather than specific things done to make therapy happen. Different therapists can practice in widely different ways, use widely different techniques at given choice points, and still be effective if they are implementing certain fundamental humanistic principles. Thus, uniformity of therapist behavior is neither expected nor desired. What is desirable is that therapists individually “be themselves” in their own unique idiosyncratic “healing ways.” Therapists will not necessarily even be consistent from one moment to the next, as they flexibly adjust to the emerging flow of interaction between themselves and the client. This includes the therapist's own continual self-discovery of new potentialities for helpful interaction through dialogue with this particular client.
Based on these core, generic principles, humanistic therapists practice in widely different ways. In all cases, humanistic practitioners recognize that their particular philosophical and theoretical positions are guiding frames of reference for interaction and practice, but are not “the truth” to be imposed on their clients. The reality of the client, of the client's own experience, and of the experiential reality created by the intersection of the therapist's reality and the client's reality, is the ultimate determinant of practice in humanistic therapy.
Stance on Differential Therapeutics
Criteria for identifying empirically supported treatments ascribe to the idea of differential therapeutics, that is, the idea that different “treatments” are needed for different disorders. Thus a different therapy approach might be needed to treat schizophrenia than to treat depression. In contrast, humanistic psychologists believe that the kind of relationship and experiences they provide can be used by anyone, regardless of their diagnosis. As we have noted, all people think, experience, value, have wishes and aspirations, and make choices. Therefore we believe that people labeled “schizophrenic” might wish to explore the basics of their engagements in life, as might people who are depressed, and learn about how their depression or schizophrenia (or whatever) is linked to these engagements. “Differential therapeutics” therefore consists of the exquisitely sensitive moment-to-moment responding we have previously referred to, wherein therapists suggest techniques or procedures in dialogue with clients and in response to what individual clients need at that moment in their therapeutic process.
At the same time, different clients might be attracted to different modalities of humanistic therapy. This is not a matter of matching diagnosis to therapy. Rather it is a matter of the particular style and content of a given therapeutic approach particularly appealing to some clients. Clients should have the freedom to choose modalities of therapy which best fit their personal needs.
Humanistic Stance on DSM and on Diagnosis
Humanistic psychologists may choose to utilize DSM where, in order to benefit their clients, such diagnoses might be useful or required. However most humanistic psychologists have reservations about, or are opposed to, the DSM classification system as a basis for making therapeutic decisions.
The DSM takes great pride in its “atheoretical” nature. However, humanistic psychologists believe, as the newer philosophies of science state so elegantly, data never can be atheoretical. Even a decision to look at certain phenomena and not others is a decision about the importance of considering these phenomena versus others. That decision cannot be made independent of a view of the nature of reality—a theory. Therefore, as in all forms of scholarship, the DSM's theoretical views needs to be clearly understood so that an informed choice can be made as to the whether such a theory is the best way of understanding psychopathology.
Symptom clusters versus symptom meanings
One of the first theoretical suppositions underlying the DSM involves the assumption that common clusters of “symptoms” point to the same underlying “disease.” The current nomenclature is more interested in categorizing clusters of symptoms than in diagnosing the meaning of the symptoms for the person. For example, all persons with certain symptoms are assumed to suffer from an “obsessive compulsive disorder.” There is little room for persons with differing “symptoms” to be manifesting similar (or even identical) problems or for persons with very similar symptoms to be struggling with very different problems. While this assumption may seem reasonable on superficial inspection, psychotherapists have long known that individuals with identical symptomatology are actually struggling with very different issues and need very different treatment approaches. Therapists for persons diagnosed as “obsessive compulsive” often speak about a group of these persons who are at high risk for developing “schizophrenic” symptoms, in contrast to many others with an obsessive diagnosis. (See Faidley & Leitner, 1993, for a more detailed discussion.)
The myth of objectivity
The DSM claims as its greatest strength the increase in diagnostic reliability associated with the development of an objective method of classifying symptoms. Faidley & Leitner (1993) argue that this claim is actually a myth of objectivity. The “objective” criteria are filled with terms that allow the clinician to project subjective values and norms into the process of diagnosis. For example, consider the “objectivity” associated with the criteria for receiving a diagnosis of Dependent Personality Disorder (301.6).
1. has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
2. needs others to assume responsibility for most major areas of life.
3. has difficulty expressing disagreement because of fear of loss of support or retribution. (Note: Do not include realistic fears of retribution).
4. has difficulty initiating projects or doing things because of a lack of self confidence in judgment or abilities.
5. goes to excessive lengths to obtain nurturance or support, to the point of volunteering to do things that are unpleasant.
6. feels uncomfortable or helpless when alone because of exaggerated fears of being unable to take care of himself or herself.
7. urgently seeks another relationship as a source of care and support when a close relationship ends.
8. is unrealistically preoccupied with fears of being left to take care of himself or herself.
Our point is not that there are subjective terms within the nomenclature; indeed, when dealing with subjective, meaning making organisms, subjectivity in the diagnostic system is inevitable. Rather, our concern is the ways the DSM masks this subjectivity and implies that these value laden, impossible to quantify terms are objective.
Further, there is a blatant contradiction between the process of more humanistic therapies and the process inherent in DSM diagnoses. As Faidley & Leitner (1993) point out, the process of objectifying the other to arrive at such a diagnosis may actually be an impediment when the therapy involves the active, subjective, mutual engagement between therapist and client. At best, time is wasted as the therapist and client have to undo the damage to the therapy relationship associated with such objectivity. R.D. Laing (1959) makes a similar point when he states, “Depersonalization in a theory that is intended to be a theory of persons is as false as schizoid depersonalization of others and is no less an intentional act. Although conducted in the name of science, such reification yields false `knowledge'” (p. 24). He then states:
It is just possible to have a thorough knowledge of what has been discovered about the hereditary or familial incidence of manic-depressive psychosis or schizophrenia, to have a facility in recognizing schizoid `ego distortion' and schizophrenic ego defects plus the various `disorders' of thought, memory, perceptions, etc., to know, in fact, just about everything that can be known about the psychopathology of schizophrenia or of schizophrenia as a disease without being able to understand one single schizophrenic. Such data are all ways of not understanding. (1959, p. 33)
Related to the myth of objectivity is the extraspective theoretical assertions of the DSM. The DSM assumes an external reality that allows for the judgment of what is “excessive,” “inappropriate,” “unrealistic,” and so forth. In contrast, most forms of humanistic psychotherapy focus on understanding the introspective realities of the client's experience. Once again, this extraspective bias limits the utility of the DSM to the practicing therapist.
Others (e.g., Caplan, 1995) have described the ways the DSM disempowers groups of persons (e.g., women) due to the nature of the diagnostic system. We want to speak briefly about another form of disempowerment within the DSM. All of the theoretical views discussed above lead to the issue of the nomenclature disempowering people in ways that may lead to more problems for the person seeking help. For example, a person labeled “paranoid” is faced with a double bind. On the one hand, the very nature of the person's experience of the world is being viewed as pathological; on the other hand, most forms of humanistic therapies rely on the person learning to have the courage to trust his or her experience of the world. A person who is told he or she is paranoid may not be able to engage the world because of concerns over whether the engagement is based upon paranoid fantasies. Such a person would be rendered powerless and helpless. Similarly, a person who could not honor his or her dependency needs because of the diagnosis of “dependent personality disorder” would not be able to honor parts of the self. Humanistic therapies emphasize the honoring of all aspects of the self. Honoring of all aspects of the self does not mean that humanistic therapists encourage paranoid clients to act on their paranoid suspicions. Rather, it means that therapists help individuals take their experience seriously and explore it. It is through this honoring that full integration of experience takes place, important differentiations and discernments are made, and exaggerated aspects such as paranoia become assimilated, balanced, and reorganized in the form of client development of healthy alertness and discerning judgment. Excessive dependency becomes integrated as a healthy capacity for intimacy, trust, and reliance on others. Pathologizing of the person's whole manner of being in the world (e.g., “paranoid personality disorder” or “dependent personality disorder”) undermines the very restorative and self-healing processes which humanistic therapists hope to mobilize.
In contrast to the DSM, humanistic psychologists take the position that psychological diagnosis is basically a professional understanding of the client and the client's struggles. We therefore believe that diagnosis is an important part of psychotherapy. However, we favor holistic, experiential diagnoses that attempt to understand persons as whole beings-in-context as opposed to preemptive labels that are concerned with inadequacies and illnesses.
Humanistic psychologists believe that diagnostic labels are professional constructions placed upon the client and are not, in any way, reality itself. This awareness leads humanistic psychologists to be highly cognizant of the power associated with the labeling of others. As such, we have a responsibility to evaluate any diagnostic nomenclature in terms of its meeting the following criteria:
1. Growth inducing. Persons seek our help in order to grow, as well as to overcome problems or deficits. As such, any nomenclature that does not point to ways in which the therapist and client can engage one another in the therapeutic journey is irrelevant. Relatedly, any system that conceptualizes client struggles as unchanging (e.g., life long, characteristic of functioning for the foreseeable future, etc.) is of limited usefulness.
2. Multiple perspectives on reality. We recognize that there are innumerable constructions of reality. We therefore evaluate any diagnostic system in terms of its acknowledgment of alternative, equally viable, systems for understanding human distress.
3. Experiential validity. We believe that a client's experience of the world is vital for a therapist to understand. As such, the diagnosis should actively involve the client and respect the client's description of the problem.
4. Theoretical relevance. We understand that psychotherapy is intimately tied to theories of persons. Therefore, we evaluate all diagnostic systems in terms of their relevance to the particular humanistic theory with which we work.
5. Broadly applicable. Humanistic psychologists deal with a wide range of persons seeking our help. Any diagnostic system therefore must be capable of understanding a wide range of persons and problems. Thus, we evaluate any diagnostic system in terms of its applicability to the entire gamut of human problems we see.
6. Relationship inducing. We understand that, fundamentally, psychotherapy is a person to person relationship in which the person of the therapist, and the relationship that is formed, are more powerful than any specific “technique.” Thus, any diagnostic system is evaluated in terms of its potential for enhancing the therapeutic connection we establish with our clients.
7. Client empowering. We believe that clients' experience of disempowerment is an important issue for many persons in distress. Therefore, we evaluate all ways of understanding clients as to the ways the system makes clients feel empowered, respected, and that their experiences of the world are honored by the professional.
Many humanistic psychologists do not believe that DSM meets the above criteria. Therefore, they have reservations about using it unless required to do so for the benefit of clients. If required to do so, they attempt to mitigate potential dehumanizing aspects of DSM diagnosis. Finally, humanistic psychologists continue to advocate for a more human diagnostic system.
Scientific Research, Knowledge, and Psychotherapy Practice
The humanistic practitioner does not believe that science as it has been traditionally defined by psychology is the only legitimate, or even the most privileged way of knowing when it comes to assessing various psychotherapy options. The humanistic viewpoint is highly critical of scientism, the belief that all meaningful questions concerning reality, and in particular psychotherapy, can be best answered by normal science alone. Humanistic psychologists, in keeping with the practices of scientists in other disciplines (including natural science), oppose hegemony in science and assert epistemological pluralism, that is, that there are multiple valid ways of knowing. Aside from scientific knowledge, humanistic psychologists assert that there are relevant understandings which may be appropriated from the arts, social studies, humanities, and popular culture, for instance, in art criticism, literary studies, biography, history, media studies, and cultural criticism. Indeed, there is the vernacular or prescientific knowledge utilized by the person on the street, that represents much of the population that is served by psychotherapy, which humanistic psychologists view as extremely important in informing practice. However, humanistic practitioners are not anti-science; we do not dismiss science in favor of these other forms of knowledge. In fact humanistic psychology views itself as a scientifically based discipline.
How does humanistic psychology respect these various ways of knowing and yet itself be and remain scientific, and without falling into a groundlessly relativistic eclecticism in which any assertion must be viewed as valid? The key lies in the humanist's conceptualization of science. Philosophers of science have distinguished two major approaches to conceiving science in psychology, what Dilthey (1894) called Naturwissenschaft (natural science) and Geisteswissenschaft (human science). Humanistic psychologists view the natural science model, which has dominated the field, as having weaknesses. Humanistic psychologists do not reject outright particular research and knowledge generated by the natural science model; we merely see it as being limited, as all research and knowledge is. What humanistic psychologists reject is the exclusive utilization of the natural science approach; we reject it as the model for psychological science because, when particular methods are identified with the science itself, it is exclusivistic in its very constitution. We view this kind of dogmatism as, in fact, unscientific. We endorse the human science model of science (Giorgi, 1970, 1994) because it is more comprehensive, capable of embracing various forms of research and knowledge in a manner that allows complementarity in an integrated overall framework. The human science approach requires not less but more rigor, and is more scientific than the natural science model, because it is more inclusive and capable of apprehending a greater complexity. We view natural science methods as offering important knowledge (and indeed draw on a substantial body of natural science research in the next section). However, we view natural science methods as being neither necessary nor sufficient in themselves for the science of psychology. Most importantly, the human science model allows and mandates research methods and conceptualizations capable of answering questions of the meaning and value of psychotherapy in the lives of individual human beings.
The conceptualization of science endorsed by mainstream psychology defines science by its appropriation of methods from the natural sciences and in doing so opposes itself chauvinistically and irrevocably to all other forms of knowledge. First, a host of limitations arise from basing psychotherapy research on the current nosology of mental disorders. Persons with multiple disorders, forms of suffering that do not clearly fall into any diagnostic category, difficulties that are social in nature—pertaining to couples, families, groups, and even society/culture—are as relevant for psychotherapy research as DSM defined populations. According to some leading theoretical positions in psychology (e.g., psychoanalysis), psychopathology and normality are not mutually exclusive and the line between them is non-existent. The need for therapy may be a practical issue to be defined by the person in light of life-goals rather than an absolute condition whose presence or absence is determined by an independent “expert.” Research must be able to approach the person not just as a diagnostic category but as a whole. Second, the requirement that interventions be specified in manualized form has the potential to be discriminatory against some forms of psychotherapy. A cardinal rule of some therapies (e.g., person centered) which may in principle defy manualization, is the mandate of not imposing predefined goals or activities and allowing the client to proceed at his or her own pace and in his or her own direction. Key ingredients in therapy, such as empathy, honesty, hope and so on may be less “implemented procedures” than personal virtues that are context dependent and not easily manipulated. Research must be able to consider therapy as an open dialogical process that is unpredictable and unmanipulable. Third, the predetermination and standardized operational definition of the dependent variable, i.e., the “outcome,” in the experiment, precludes research from assessing the full spectrum and complexity of psychotherapy outcomes. Predefinition, measurement, and aggregate analysis of results fail to capture unanticipated, uniquely individual, and nonmeasurable benefits. Besides limiting our understanding to what can be measured, it even fails to inform us about the meaning of a measured change in a given variable in the participant's life. Research must be able to capture the nonquantifiable and the meaningful. Moreover, although experimental methodology presumes to be atheoretical, the implicit theory guiding it is one of linear causality. The person being analyzed, often in aggregate, is viewed as a mere outcome or effect of a treatment or cause. Research must be able to consider the participating individual as an agent and interpreter of the therapeutic situation. The probabilistic support of efficacy hypotheses typical of experimental investigations are difficult to apply to real life persons, and many studies are virtually noninterpretable at the level of the individual person. Research focused descriptively and interpretively on individual persons in depth is needed in order to complement hypothesis testing by aggregate analyses and inductive inferences.
By contrast, the human science tradition, endorsed by humanistic psychology, asserts that because human beings are different from physical things, they require the development of a different and special approach—attitudes and methods—in order to be properly scientific. The essential attitude is that of empathy, in contrast to disinterested objectification, which may or may not be required by a particular research problem. The best data are those that reveal the meaning of the human subject matter, for example, psychopathology and psychotherapy, under consideration. Artistic and literary expressions may at times, in this regard, be judged as superior to measurements by psychological scales. Rather than being delimited to statistical calculations, analysis requires procedures that are capable of conceptualizing the whole person; apprehending of multiple contexts and perspectives; interrelating constituents; articulating temporal transformations; distinguishing idiosyncratic, typical, and highly general patterns; grasping the essential; and so on. Experimental efficacy studies and quasi-experimental effectiveness studies (Seligman, 1996), far from being sufficient in themselves to constitute a science of psychotherapy, must be understood in the context of this larger scientific search for the meaning(s) and values of these psychotherapeutic practices in human life.
The humanistic position is supported by some of the most eminent historians and philosophers of science in our field. Koch (1994a), for instance, suggests that psychology is now undoubtedly in a pluralistic phase in which the hegemony of what Toulmin and Leary (1994) call “the cult of empiricism” is thankfully coming to an end. Koch (1994a) believes that this breath of life in psychology is opening the way for psychology's dialogue with the humanities, for the legitimacy of contemplative and critical theoretical reflection, and for exciting research methodologies including the qualitative—for example, the hermeneutic, phenomenological, and ethnomethodological. Koch (1994b) and Toulmin and Leary (1994) assert that this trend does not make psychology unscientific but actually makes psychology more like such physical sciences as biology and physics in their openness to modes of inquiry beyond strict experimentation (see also Polkinghorne, 1983, 1992). We affirm Giorgi's (1985) broadened characterization of what makes a science, namely that the knowledge quest is systematic, rigorously methodical, and self critical, because it allows and even demands the greatest possible breadth in the psychologist's scientific considerations and the uniqueness of knowledge required to apprehend human meaning.
Psychotherapy with persons is unlike the application of a particular chemical to an inert substance; in the former process, meanings, values, human freedom, indeterminacy, and a multiplicity of interpretations of the matter of “usefulness” cannot be ignored. The human issues involved call for multiple research methods, some of which are unique to human science. The quantitative methodology upon which empirically supported treatments are exclusively based misses the participating individual as an interpreter and agent in the therapeutic situation. The qualitative forms of empirical inquiry into the process and meaning of psychological interventions—such as case, phenomenological, existential (Daseinsanalytic), hermeneutic, psychoanalytic, ethnomethodological, and grounded theoretical, many of which are designed specifically to provide insight into the complex experiential structure of the therapeutic process with close fidelity to individual participants as such, are totally left out of consideration. Beyond those based in natural science experimental methods, a host of scholarship that aims at reflection and integration in practice areas is disregarded or relegated to a low status despite their important contributions to the evaluation of psychological interventions. The critical theory literature which subjects various interventions to social and historical scrutiny also offers crucial insights into the meaning and value of procedures. With regard to outcome measures, or more appropriately outcome understanding, any evaluation of psychotherapies should hold high the principle of viewing the outcome in question both from the standpoint of the theory of personality and change that internally guides it and from the standpoints of alternative theories and perspectives. Ultimately, in the view of humanistic psychologists, documents that purport to set guidelines for psychotherapy practice should not narrowly focus on utility but on the more general question of human meaning, value and purpose.
As stated above, we are not arguing that formal research, the present nosological system, the manualization of procedures, and the random control trial method have no value or that they have no place in the formulation of guidelines. Rather, we believe that their being given priority over or being used to the exclusion of other alternatives too narrowly restricts the formulation of guidelines and is disastrous for the science and practice of psychotherapy. The principles expressed in the empirically supported treatments approaches should be used as heuristics among others within a broader framework rather than as a template, that is, rather than being imposed exclusively on all formulations of guidelines or other documents that specify principles of effective practice. We advocate the proposal of a variety of documents specifying criteria for effective practice, each reflecting a different orientation, possibly achieving distinctive results, and embodying a unique set of values. We believe that unity may be maintained in an inclusive effort that respects this plurality of approaches in our discipline. For a unified, comparative, and general knowledge of this variety of psychotherapeutic guidelines or principles of effective practice, we would recommend a broader procedure that takes maximal account of practitioners' experience; that acknowledges numerous ways of conceptualizing the “problems” or “situations” that are addressed by psychological interventions; that respects modes of practice that are in part dictated by the spontaneous directions of clients and that unexpectedly cut across or synthesize the procedures of different schools; that utilizes case study, qualitative research methods, socially critical thought, philosophical reflection, and various forms of non-scientific discourse along with surveys and experiments in the evaluation of psychological interventions.
Finally, we must say a word about the use of the general disciplinary stock of psychological knowledge about therapy, that is, how science is to be related and applied to practice. Psychotherapy is not itself science, an activity solely involving the perspective and power of the professional; it is a practical activity that involves (at least) two people. Of course one of those people is a professional with specialized, scientific, disciplinary knowledge and practical skills, but this general knowledge and general skill, as formed outside any particular therapeutic situation, must be modulated by means of a more immediate, participatory knowledge of the unique, concrete situation at hand, which always includes the co-constitution of the one served by the practice. In order to be properly attuned to the field of practice, the practitioner must utilize any and all disciplinary or general knowledge in the context of his/her concrete dialogue with the person(s) served by the intended practice, and a highly concrete, individualized knowledge of that particular situation. It is never to be assumed or taken for granted that a possible course of action—whether suggested by a poem, cultural criticism, a philosophical text, a psychological theory, a psychotherapeutic manual, an experimental outcome study, a cost-benefit analysis of a third party payor, or even a careful phenomenological comparison of the meanings of different intervention outcomes—is appropriate in the particular situation. Such knowledge at best presents relevant possibilities which must be evaluated by psychological practitioner and person(s) served together in dialogue in light of their shared understanding of that situation. The situation apprehended in dialogue takes precedence both over the psychological practitioner's own individual viewpoint and over the body of knowledge utilized by that practitioner. In other words, scientific knowledge may and should inform practice, but it should never dictate it as an authority in a one way manner. At best, it provides “applicable options” to be considered within the dialogue about the situation addressed in the therapy, this dialogue being the ongoing and most legitimate arbiter of its meaning and value. It is not enough to say that a clinician's experience may lead him/her to make an exception to a “scientifically established” guideline provided that there is a compelling rationale. Guidelines and statements of principles of practice should -recommend without prescribing. The most important expertise of the psychotherapeutic practitioner is his/her ability to understandingly relate scientific, disciplinary and other perspectives to the unique situation that presents itself in therapy. The formulation of guidelines and recommendations about principles of practice should stress that they are for educational purposes, to contribute to the knowledge of those who consult them and to enhance his/her understanding of options for action rather than to override the exigencies of the concrete situation apprehended in dialogue.
The humanist's commitment to avoid scientism is not a rejection of science, for we advocate a maximally informed practitioner who is familiar with and appropriately uses the relevant scientific literature. However, this practitioner must be conversant with more than science, and most importantly, does not impose what follows from science on those served by it but allows them, the non-scientists, the people served in the lifeworld, to play the chief role in accepting or rejecting any knowledge and procedure that the psychologist has to offer. That, we believe, is an ethical imperative of the person who is informed of scientific research in the relationship with any potential beneficiary of that knowledge. Only in this way does science humbly serve humanity rather than vitiate it.
Research Findings on Humanistic Services
In this section we briefly review the psychotherapy research that supports humanistic practice. Much of the research utilized has been done using aspects of traditional “natural science” formats, such as randomized clinical trials, although, congruent with our paradigmatic values, most of these studies were not conducted with manualized treatments for specific disorders. We have previously suggested that RCTs may not be the optimal method for evaluating the usefulness of a humanistic therapy. Nonetheless, studies using this format, preferred by others for developing guidelines, have provided data sufficient to justify the usefulness of humanistic therapies (Elliott, 2002). We organize our research review to first show the empirical support for the two basic postulates that underlie humanistic practice from a wide range of perspectives. Next we consider outcome research on a) changes in personality functioning, b) changes in psychological dysfunction, and c) on the facilitation of specific individual types of outcomes, or “mini-outcomes.” Finally we consider research on psychotherapy process.
Two Basic Humanistic Postulates
First, from a humanistic perspective, client agency and its facilitation is the ultimate “engine” which drives therapy. Clients, while they may not initially be aware of it, or even experience themselves as such, are the ultimate experts on themselves and on what will be viable healing directions for them to take, within the constraints of society and the constraints involved in their life structures. Therefore, therapeutic agendas must always be developed through dialogue with clients, and represent co-constructions of therapists and clients together. Further, the power to make change ultimately lies in clients' hands. Clients must decide whether or not to adopt, implement and enact therapeutic goals and directions. Change follows from how they implement whatever they glean from the therapy experience, not from any mechanistic impact of “expert interventions” imposed on them by the therapist.
There is a good deal of research compatible with the postulate of client agency as the primary healing force in therapy (Bohart & Tallman, 1999). Direct support comes from qualitative studies demonstrating client agency during the therapy process (Rennie, 1990, 1994; Watson & Rennie, 1994), and evidence showing that client factors account for the largest proportion of variance in successful therapy outcome (Lambert, 1992). This latter finding has led two experts on psychotherapy research to comment: “Another important observation regarding the client variable is that it is the client more than the therapist who implements the change process... Rather than argue over whether or not `therapy works,' we could address ourselves to the question of whether or not `the client works'... As therapists have depended more on the client's resources, more change seems to occur” (Bergin & Garfield, 1994, pp. 825-826). Other evidence for the power of clients' own agency and self-healing capacities comes from studies of journaling (Pennebaker, 1990; Segal & Murray, 1994), and self-help programs (Christensen & Jacobson, 1994). Gold (1994) has provided qualitative evidence of cases where clients spontaneously engaged in their own forms of integrating different approaches to psychotherapy together. Duncan, Hubble, and Miller (1997) have demonstrated that cases found to be “impossible” or untreatable in previous therapy were typically untreatable because the therapists did not try to coordinate their practices with the client's frame of reference, nor utilize the client's own capacity for self-healing. When these factors were taken into account, these clients became “treatable.” Evidence for the existence of human agency in general comes from studies by Howard (1996) and Rychlak (1994).
The second postulate is that the therapist's presence as person and the therapeutic relationship are the basis of the therapist's contribution to the healing process, more so than the particular type of therapy practice or the techniques used. There is considerable evidence for this postulate, perhaps more so than for any other “fact” about the nature of psychotherapy (Norcross, 2002). A number of studies have found that some therapists are more effective than others (Lambert & Bergin, 1994; Najavits & Strupp, 1994), even in cases where therapists are following treatment manuals (Luborsky, McClellan, Woody, O'Brien, & Auerbach, 1985). Moreover, therapist/relationship factors account for 30-35% of the variance in outcome (Gaston, Marmer, Gallagher, & Thompson, 1991; Lambert, 1992), considerably more than the 15% accounted for by techniques or therapeutic approaches (Lambert, 1992). The alliance between therapist and client appears to be the most important factor in outcome across psychotherapies (Horvath, 1995), including even the use of psychotropic medication (Krupnick et al, 1996).
In particular, there is evidence that therapist empathy correlates with outcome (Bohart, Elliott, Greenberg, & Watson, 2002), as does therapist affirmation, warmth, or positive regard (Farber & Lane, 2002). Therapist congruence or “self-relatedness” also correlates with outcome (Klein, Kolden, Michels, & Chisholm-Stockard, 2002; Orlinsky, Grawe, and Parks, 1994). On the converse side, studies have found that therapists whose behaviors and strategies are judged as punitive, belittling, cold, critical, hostile, or rejecting are less effective (Gaston, Marmer, Gallagher, & Thompson, 1991; Najavits & Strupp, 1994). A qualitative study by Schneider (1984) found that clients' perceptions of positive counselor characteristics included their personal involvement, which consisted of being straightforward and integrated, caring, nonjudgmental, and experientially empathic. Secondarily, perception of positive counselor characteristics included the capacity for technical restructuring, which was comprised of cognitive restructuring, experiential restructuring, exploratory restructuring, and mirroring. Finally, perception of positive characteristics included other positive themes such as intuition and authoritativeness. Negative characteristics included inappropriate personal involvement which included being seen as deceptive and lacking in personal integration, excessively friendly or aloof, excessively judgmental or nonjudgmental, and unempathic, as well as rigid. Schneider concluded that effective counselors were seen as appropriately personally involved, warm, empathic, relatively nonjudgmental, integrated, knowledgeable about what they are doing, and using appropriate skills. The importance of maintaining an “optimal therapeutic distance”—not being either overly involved or overly disengaged—has also been supported by Leitner (1995).
In sum, research supports the humanistic postulate that client agency is a major generative factor in therapeutic change and that the therapist and therapeutic relationship are more important than the therapy or method practiced. Effective therapists take into account the client's frame of reference, and facilitate and rely upon clients' own self-healing capacities. In addition they are affirming, empathic, congruent, knowledgeable and skilled in what they do, and maintain an optimal therapeutic distance.
A major focus of humanistic therapy is the promotion of positive personality growth and development. The first question is therefore whether there is evidence that humanistic therapies do promote positive personality change. With regard to client-centered therapy, the most empirically studied of the humanistic therapies, research has indeed found that client centered therapy promotes positive personality growth and self-concept change in a wide range of clients (Ends & Page, 1959; Elliott, Greenberg, & Lietaer, in press; Seeman, 1965; Shlien, Mosak, & Dreikers, 1962). Gestalt therapy has been found to lead to greater adjustment (Beutler, Frank, Schieber, Calver, & Gaines, 1984; Cross, Sheehan, & Khan, 1982; Strumpfel & Goldman, 2002). Bednar and Kaul (1978) review a variety of studies on marathon and encounter groups which find positive changes in things like locus of control, self image changes, personal actualization scales, interpersonal orientation, behavior ratings, self-ideal congruence, self-direction, and creativity.
In terms of helping clients overcome psychological dysfunction, client-centered therapy has been found to help clients alleviate personal distress across a wide range of kinds of problems in living (Elliott, Greenberg, & Lietaer, 2002). This includes reduction in symptomatology in depression, schizophrenia, anxiety disorders, interpersonal problems, stress associated with cancer, and personality disorders. Client-centered therapy has also been shown to facilitate alcoholics staying abstinent (Ends & Page, 1957), and the reduction of delinquency in adolescents (Truax, Wargo, & Silber, 1966). A psychodynamic-interpersonal approach which combines elements of both psychodynamic and humanistic therapy has been found to be as effective as a cognitive-behavioral approach for depression at a one-year follow-up (Shapiro, 1995). Focusing procedures have been shown to be helpful to clients coping with cancer, and in weight reduction (Greenberg et al, 1994). Process-experiential therapy has been shown to help clients overcome depressive symptomatology (Greenberg & Watson,1998). Gestalt therapy has been shown to be helpful with depression (Beutler, et al., 1991).
In sum, there is evidence that client-centered therapy, Gestalt therapy, and encounter groups do indeed promote personal growth as hypothesized by humanistic theory. In addition, client-centered therapy has been shown to be helpful to individuals with a wide range of DSM dysfunctions. Recently, Elliott (2002) and Elliott, Greenberg and Lietaer (in press) have concluded that there is sufficient evidence that these and some other humanistic therapies, such as process-experiential therapy, should be considered "empirically supported treatments."
Proximal or “Mini” Outcomes
Greenberg (1986) has emphasized the importance of looking at “mini-outcomes” in psychotherapy research. Mini-outcomes are specific in-session outcomes that are associated with psychotherapy process. From a humanistic point of view, these changes can be considered to be real outcomes of psychotherapy because they are changes that occur as a result of the therapy and because they often represent outcomes desired by clients. However, they do not count as outcomes under the criteria of the empirically supported treatments movement because they are not alleviations of DSM (or similarly defined) disorders. A wide range of specific mini-outcomes has been found in humanistic therapies. For instance, the Gestalt two-chair procedure has been found to help clients resolve internal conflicts (Greenberg, 1984), and the Gestalt empty-chair procedure has been found to help clients resolve anger and hurt feelings and other forms of “unfinished business” with significant others (Paivio & Greenberg, 1995). An “evocative unfolding” procedure (Rice & Saperia, 1984) has been found to be useful in helping clients resolve feelings about situations where they behaved in ways they did not understand. Mahrer's (1996) experiential therapy has been shown to be associated with the production of several “good moments” (Mahrer & Nadler, 1986) in psychotherapy, such as the arousal of strong feeling, and the appearance of new personality-process states (Mahrer, Lawson, Stalikas, & Schachter, 1990). Clarke (1989, 1991) studied the process of “creating meaning” in emotional crises and found that therapists who used metaphor, who helped condense feelings into words, who helped synthesize the relationship between thoughts and feelings, and who helped symbolize the discrepancy between a cherished belief and an experience, facilitated the achievement of greater clarity and the reduction of discomfort with respect to the crisis. Other findings from studies on experiential therapies have found that they lead to: better understanding of self, problems, and others, experiencing of hope and relief, and coming to own or value aspects of the self (Greenberg, et al., 1994). These findings of specific effects from humanistic therapies are important first because these mini-outcomes have been found to correlate with eventual global therapeutic outcome (Greenberg et al., 1994). Second, these changes are important because clients often come into therapy seeking outcomes such as increased insight, greater awareness of feelings and experience, a greater capacity to experience, or resolution of unfinished business with significant others.
Conditions for Effectiveness
We have already discussed the research for the two basic postulates of effective humanistic practice: respecting client agency and establishing a facilitative therapeutic relationship. In addition humanistic therapists generally believe that therapy is more effective when it includes a focus on the emotional and experiential dimensions of human functioning, when it facilitates dialogue which takes clients to deeper levels of feeling and thinking, and when therapy is a collaborative process. In regard to the first of these, a focus on feelings and experience has been found to be associated with positive therapeutic change (Greenberg et al., 1994; Mathieu-Coughlan & Klein, 1984; Orlinsky & Howard, 1986). With regard to the second, Toukmanian (1992) has found that therapist responses oriented towards facilitating clients' differentiation and reorganization (“reschematization”) of meaning facilitate deeper levels of client perceptual processing. Deeper levels of client perceptual processing have in turn been found to be associated with better client outcome. Sachse (1990, 1992) has found that therapist responses which challenge the client to go deeper into their experience do indeed facilitate this process, and client depth of processing is associated with therapeutic outcome. Wexler and Butler (1976) found that therapist expressiveness facilitated expressive use of language by clients. The collaborative use of therapeutic metaphor has been found both to facilitate clients' work with inner experiencing and with clients going to deeper levels of perceptual processing (Angus & Rennie, 1989; Toukmaninan, 1992). With regard to the third of the above hypotheses, it has generally been found that a collaborative therapist style is associated with therapeutic outcome, especially when seen through the eyes of the clients (Orlinsky, Grawe and Parks, 1994), and that directive behavior on the part of the therapist in the later stages of therapy is associated with negative outcome (Schulte & Kunzel, 1995). Other findings suggest that confrontation can be helpful if a) it is done to strength rather than to weakness, and b) it is done experientially (Anderson, 1968; Orlinsky, Grawe, and Parks, 1994).
Humanists believe that the individual therapist is far more important than the kind of therapy being practiced or the particular methods being used. In fact, different therapists practicing “the same” therapy may operationalize its methods and principles in widely different ways. For instance, it has been found that client-centered therapists, while remaining true to general client-centered principles, practice in widely different ways (Hart, 1970), and it is well known that Gestalt therapists differ widely among themselves. Different therapeutic modalities are really different means whereby different therapists optimize their own particular ways of being helpful. Thus, diversity within any given therapeutic approach is not something to be manualized away, but rather to be prized. This means that conclusions concerning specific approaches and who they are “for” are somewhat out of paradigm. With this proviso in mind, however, there is some research suggesting there are those for whom some approaches are more helpful than others. For instance, there is some evidence that clients with better general social skills who are high in reactance (i.e. independence) do better with client-centered procedures, while clients low in reactance do better with a Gestalt approach (Greenberg et al, 1994). In addition, internally oriented clients may profit more than externally oriented clients in client-centered therapy. Clients' general openness and interest in inner experience may be useful predictors of success in experiential therapy. In encounter groups, clients whose expectations do not match the practices of the group are more likely to have a negative experience (Bednar & Kaul, 1978). Mahrer (1996) has found that his experiential approach can be used by clients, regardless of diagnosis, who are comfortable with his therapy format. His approach to differential therapeutics is simply to have a trial session or two with the client to see if he or she finds it a comfortable approach. Overall, these findings suggest, not that a particular therapy should be prescribed for a particular kind of client, but rather, that therapists and clients together might wish to consider the use of different styles and techniques, depending on what fits with the client.
Summation of Research
In sum, based on the evidence, effective humanistic therapists are collaborative rather than highly directive, warm, empathic, congruent and genuine, provide a safe, understanding environment, support the expression of feelings, help clients organize and articulate their experience, and help them clarify and resolve problems. They respond in ways that facilitate experiencing and moving to deeper levels of understanding. They may use sensitively appropriate experiential exercises at appropriate times, such as Gendlin's (1996) focusing technique, or the Gestalt two chair or empty chair techniques. They confront clients' strengths and resources, and confront in an experiential manner. Therapists who practice in accord with these conclusions can be said to be practicing in an “evidence-based” or “empirically-supported” fashion.
Recommended Principles for the Provision of Humanistic Services
Following are recommended principles for the practice of helpful and ethical humanistic psychotherapy. These recommendations reflect general humanistic principles and what has been established through empirical research. Within the general framework of these principles individual humanistic therapists practice in different ways while still remaining faithful to these principles.
I. For Whom Is Humanistic Therapy Appropriate?
The first criterion for a client engaging in humanistic therapy as opposed to some other kind of therapy is that the client finds the process useful and rewarding. It is appropriate for clients who find the process enriching or emotionally challenging in a positive way. DSM diagnosis is irrelevant to whether or not a client chooses humanistic therapy, since humanistic therapies are not conceived of as medical-model treatments for disorders. Matching humanistic therapy with diagnosis is not relevant within this paradigm. Clients typically choose humanistic therapy because they have more fundamental, important, or vital goals than only the elimination of a specific DSM disorder. They may choose humanistic therapy because they ultimately wish to know more about their basic choices in life, their basic values, to access their deeper potential, and to live deeper, more authentic lives (Mahrer, 1996). Or they may choose a humanistic therapy because they want to be treated or viewed in a certain way, i.e. as whole people, with competency and personal dignity, over and above their having problems in living.
Humanistic therapy is therefore appropriate for people who frame their goals as striving for deeper personal development rather than symptom removal alone. If a client is primarily interested in symptom removal and wishes to achieve that through the use of a specific medical-model type of technological treatment which has been empirically studied for that disorder, the humanistic psychotherapist will either provide such a treatment if he or she is qualified and wishes to do so, or will refer the client. Humanistic therapists recommend alternative approaches if it better serves clients' needs. Otherwise, if clients decide they wish to explore their problems in a more holistic fashion, the humanistic therapist will work with them. In so doing, humanistic therapists may themselves utilize symptom-focused approaches as an initial step towards more holistic work if necessary. It is important to note that clients may not seek deeper and more holistic changes initially, and that humanistic therapists do not demand such changes, but that they provide the opportunity for such changes in conjunction with the client's needs as therapy proceeds (Schneider & May, 1995).
This means that humanistic therapists prefer to work in contexts where clients choose to enter therapy or seek humanistic services volitionally. If working with someone required to seek services, say an adolescent brought by parents, or a court-referred client, humanistic therapists stay true to their principles, treating these individuals as agents, rather than as “cases” to be “treated” and “cured” by the expert of their “disorder.” Humanists believe in one sovereign entity dialoguing with another, that if they do not take the client's viewpoint seriously and dialogue with them as a sovereign agent, then no therapy can take place.
II. Appropriate Practice
There are many different modalities of humanistic therapy. However humanistic therapists can be said to be practicing effectively if the following conditions are fulfilled.
A. Client's role in therapy. First, humanistic therapists respect the self-healing potentialities of clients. They also respect and rely upon clients' agency. They do not adopt a paternalistic attitude of expert who is to decide for the client what the appropriate treatment is and what the appropriate changes are for the client to make. Clients must be fully involved in all treatment decisions as co-equal participants, both as a matter of ethics and as a matter of effectiveness. Solutions always take into account the client's frame of reference.
B. Diagnosis and therapeutic process. The following issues apply:
1. The practice of humanistic psychotherapy is highly individualized. Humanists focus on the uniqueness of the individual, and problems are embedded in the whole person-situation context. In that sense there is no such thing as a standardized problem. It is therefore usually out-of-paradigm for the therapist to choose a standardized treatment for the client based on some nomothetic category. DSM diagnosis is not typically used as a matter of making treatment decisions. If diagnoses are used, they are the types of diagnosis which help therapist and client together decide upon goals and strategies, and are usually more specifically framed in terms of problems, life themes, and issues with which the client is struggling. These kinds of diagnoses are always provisional, and subject to continual re-evaluation.
2. In this regard, humanistic therapists favor diagnosis which is holistic, experiential, and descriptive rather than evaluative, and which tries to capture the flavor of the whole person in his or her life context. This is in contrast to a medicalized approach that focuses on the attachment of diagnoses which represent the person primarily in terms of pathology. Diagnostic systems are evaluated in terms of their relevance to theory, the range of applicability for understanding all human beings, their ability for enhancing therapeutic connection with clients, and their ability to help clients feel respected and empowered.
3. Most humanistic therapists adopt an inductive, discovery-oriented approach to psychotherapy practice. Solutions to client problems are individually and jointly created and discovered through the evolving therapy process. In this sense solutions and directions in therapy are often new and unexpected emergent products of the particular interactive process jointly created by therapist and client. This makes the concept of a standardized preset outcome goal associated with a preset standardized treatment protocol irrelevant for many humanistic therapists. As a result, developing a preset treatment plan for a client could be out of paradigm for many practitioners.
4. In contrast to a prescriptive approach to psychotherapy where the expert therapist decides upon a treatment for the client, the humanistic therapist's goal is to be able to respond flexibly and creatively with a given client. The basic therapist skills are that of flexibility in the moment and responsiveness. Humanistic therapists are adept at process skills: tracking the unfolding process between themselves and the client, and responding in a facilitative way to whatever potentialities are emerging in the moment.
5. The core process in most humanistic therapies is therefore dialogue. It is through co-constructive dialogue with clients that directions and solutions in therapy emerge. Humanistic therapists may use a variety of techniques but these are chosen with sensitive relevance to what is happening in a given moment between therapist and client, and are used as part of the therapeutic dialogue. This means that techniques are not applied mechanistically, but rather are used as part of the ongoing discovery and creation process.
C. Therapeutic relationship. The following issues apply:
1. Humanistic therapists strive to provide a trusting relationship, consisting of an affirmative, respectful attitude towards the client, as well as empathic understanding of the client's frame of reference. This means that they basically respect their clients as agents in their own right, as the experts on their own experience, and as authentic sources of experience. They listen to clients as “equals”, are interested in clients' subjective worlds, grant that these subjective worlds have their own internal coherence and validity, realize that all change must flow from and respect the intrinsic logic of these subjective worlds, and that all change is ultimately made out of the “stuff” of these subjective worlds—including clients' experiences, values, philosophies, fears, deepest wishes, and intuitions.
2. Additionally, humanistic therapists are mutually involving, transparent, authentic and genuine. This means they are “in relationship” to the client. They do not merely “provide” a relationship as if it were a drug or a palliative. Being “in relationship” means that they are willing to meet the other person as another person. This means the humanistic therapist is willing to be human, i.e. to be personally affected by the encounter with the client, share feelings and thoughts, disclose to the degree that it is respectful of the particular relationship with the client, allow him or herself to be “known” by the client, and promote appropriate mutual two-way empathic sharing.
3. While respecting the client's subjective world, the humanistic therapist, in order to be genuine, also shares his or her own perceptions. These are shared as his or her own perceptions, not as “the truth provided by the expert.” In this respect, humanistic therapists may confront when appropriate. They give their own perspectives on the client's behavior and experience, while respecting the client's perspective. Confrontations are accomplished in a way which emphasize client potentialities and strength.
4. Humanistic therapists realize that it is important to respect the “psychological and physical space” of the client and the client's boundaries. They therefore strive to maintain an optimal therapeutic distance and to pay close attention to demonstrating respect for the client’s boundaries.
5. Within the therapeutic relationship humanists strive for an optimal balance between therapeutic support and challenge, carefully titrating levels of support and challenge in consideration of the resilience of the client and the trust level achieved within the therapeutic relationship. Humanists challenge clients to go further through sensitively timed confrontations, and through responses which invite clients to venture deeper into their experience, thoughts, values, and issues.
6. Because the relationship is genuine and collaborative, humanistic therapists are willing to be wrong, and to be educated by the client. They realize that the client knows more about some things than does the therapist—particularly about the client. Therapists are particularly willing to be educated by those whose experiential backgrounds are different, e.g., whose cultural, gender, or other kinds of experiences are different. Humanists realize that all therapeutic growth emerges creatively out of a synergistic meeting of two subjective realities, and thus whatever the therapist has to offer must be mapped into, reworked, and transformed to meet the different experiential reality of the client. No theoretical idea, no technique, no therapeutic goal, will look “the same” or have the same meaning in different interactions with different client subjectivities.
7. Humanistic therapists recognize that any therapeutic engagement occurs with a context that is situated culturally, historically, geographically, and socio-politically. Humanistic therapists are sensitive to the need to bring to awareness humanly relevant contextual resources and potential obstacles that because of situational inequities might not be immediately discernable to the client.
D. Facilitative therapeutic processes. The following issues apply:
1. Humanistic therapists pay attention to client experience and invite clients to move into deeper levels of experiencing of self and of relationships.
2. Humanists believe that therapeutic learning and change is most often promoted by processes that involve experiencing and are not merely cognitive and intellectual. Accordingly, they facilitate nonrational, intuitive, and experiential modes of knowing. They believe such modes of knowing are particularly involved in liberating client potential and creativity for new ways of being and behaving.
3. Humanists may therefore use techniques and procedures that facilitate nonverbal, bodily, or experiential modes of self and interpersonal exploration and discovery.
4. In this regard humanists are also interested in the facilitation of emotional experiencing and expression, and may strive, as part of liberating client potential for change, to provide the opportunity for the experiencing and expression of strong levels of feeling.
III. Social and Legal Matters
A. Medication. Beyond possible legal requirements, humanists would not typically require a client to seek medication. However humanists make clients aware of the possibility of the use and implications of medication, and help clients decide for themselves if they wish to avail themselves of such services.
B. Societal Responsibilities. Humanists are agents of society as well as of the individual and will take action to protect society from clients, even at the cost of the destruction of the therapeutic relationship, if necessary.
C. Suicide. Humanistic psychologists consider the issue of client suicide most seriously, and take seriously their duty to have a cogently thought out intellectually rigorous position that is respectful of client integrity.
D. Empirically Supported Treatments. Humanistic psychologists recognize that for purposes of demonstrating the usefulness of humanistic psychotherapies to some governmental agencies and third-party payers that there is some usefulness in being able to show that humanistic therapies can be supported under the empirically supported treatments guidelines. Accordingly Division 32 supports and appreciates the efforts of researchers who have shown that some humanistic therapies meet the criteria for being empirically supported treatments (Elliott, 2002; Elliott, Greenberg, and Lietaer, in press). Nonetheless, we reiterate that the empirically supported treatments criteria are not paradigmatically congruent with humanistic theory and practice and are therefore not adequate for the evaluation of humanistic psychotherapies. The grounding and legitimzation of humanistic psychotherapies is based in other criteria, as have been spelled out in this document.
Humanistic Psychotherapy Training
The following is an ideal framework for training humanistically oriented therapists. In our view, students should receive such training, over and above their conventional training, if they are to be trained within a humanistic context. Drawing from a humanistic philosophical base, the training of humanistic therapists reflects a variety of orientations. In general, these orientations embrace a holistic conception of the human being, draw on a growth model of dysfunction, emphasize subjective processes, and stress dialogue over interpretation or advice-giving. Humanistic therapy training includes but is not exhausted by client-centered, gestalt, somatic, existential, expressive, experiential, constructivistic, transpersonal, archetypal, imagistic, humanistic-psychoanalytic, and group process modes of practice.
Specifically, humanistic therapy training entails a broad and deep understanding of persons. This understanding considers people in their intrapersonal, interpersonal, cultural, political, economic, mythic, spiritual and historical contexts. The thrust of humanistic therapy training is to cultivate a whole human being as a ground for that human being's development as a practitioner.
In keeping with recent therapy process and outcome studies, humanistic therapy training attends to the person of the practitioner first, and secondarily to his or her technical abilities. In particular, humanistic therapy training emphasizes the personal growth of the therapist-trainee through courses in holistic psychology and psychotherapy, philosophy, the arts, group process, critical thinking, and personal therapy.
Ideally, humanistic therapy training also entails a systematic immersion in qualitative modes of inquiry. While quantitative methodologies may be drawn upon as an adjunct, humanistic therapy training emphasizes such qualitative methodologies as case studies, grounded theory, ethnomethodology, relational studies, and hermeneutics to vivify the contexts within which clients dwell.
Central to humanistic therapy training is the attention to process dimensions of therapeutic encounters as well as to content aspects. By process dimensions, we mean attunement to how clients speak or express themselves as well as to what they say or convey overtly. Humanistic trainees develop a sensitivity to tacit areas of awareness--gestures, vocal modulations, fluctuations in breathing, facial expressions, body postures, and interpersonal atmospheres, as well as attune to more overt modes of meaning and expression. In addition to learning about test data, the DSM, and standardized manuals-which from our perspective have significant but limited value-humanistic trainees learn to formulate rich, phenomenological descriptions of their clients that take into account the multifacetedness of clients' experience.
In short, humanistic therapy training utilizes humanistic philosophical principles to cultivate sensitive and well-rounded practitioners. These practitioners provide a range of conditions to clients through which clients can grow, develop meaning, and realize potentials.
Ethics in Humanistic Practice
As members of the American Psychological Association, humanistic psychologists have developed ethical positions consistent with APA's (1992) Ethical Principles of Psychologists and Code of Conduct. In order to document a uniquely humanistic perspective on psychological ethics, this section of the Guidelines will interpret the general ethical principles of the APA (specifically the Preamble and General Principles section of the ethical code) from a humanistic perspective. We will do this by mirroring the format of the Ethical Principles, commenting on each section in terms of the special ways that humanistic psychologists apply the principles.
It is important to state that nothing written in this section should be interpreted as implying that Division 32 does not endorse APA=s code of ethics. Much of what is written should be interpreted as implying that all professional decisions have many layers of complexity as well as ways they may be advantageous or harmful to those being served. Thus, humanistic psychologists evaluate specific actions in terms of a number of different value positions. By elaborating on the code of ethics, humanistic psychologists are laying out a model of how certain core values can, and perhaps should, be used in the application of the ethical principles.
Humanistic psychologists agree that they must develop a valid and reliable body of scientific knowledge based upon research. This knowledge is necessary to improve the lives and knowledge of persons and society. Further, humanistic psychologists emphasize the importance of viability (i.e., utility) in the development of knowledge. They also support the central importance of freedom of inquiry and expression in research, teaching, and publication. In particular, they believe that the development of valid and reliable scientific knowledge has to include perspectives in addition to traditional experimental, survey, statistical, and other positivistic research designs. These additional approaches include phenomenological, narrative, qualitative, interpretive, human science methodologies, case studies, and other post-positivistic methods and designs. Therefore, humanistic psychologists strongly support the freedom to publish, teach from, and draw conclusions from these varied approaches to science. They believe that such methodological eclecticism is vital for the development of a human science -- a science which results in human service, not just published data.
Like all professionals, humanistic psychologists are charged with evaluating the relevance of studies for their professional activities. In order to make such an evaluation, humanistic psychologists consider the relevance of the study to the mission of helping human beings live better and more whole lives. Further, before using any study to make a decision that affects the welfare of persons or the public, humanistic psychologists carefully evaluate the study on the basis of whether the research methodology employed may distort the understanding of the problem and therefore lead to conclusions that are incomplete or detrimental to the safety and general welfare of those whom we serve.
Humanistic psychologists agree that it is important to aspire to the highest standards of professional conduct. They also encourage ethical responsibility in colleagues, students, supervisees, and employees. Consistent with humanistic principles, this encouragement involves genuine respect and concern for other persons. In particular, humanistic psychologists openly acknowledge that ethical principles, as abstract values and ideals, are culturally variant and are subject to different interpretations by different persons. In their discussions with colleagues, students, supervisees, and employees, humanistic psychologists stress the spirit of the ethical principles over the letter of any particular behavioral mandate and explore the concrete ways that spirit may be manifested in concrete actions. Finally, consistent with humanistic principles, they recognize that behaving in a professionally ethical manner means being committed to their own personal growth such that they live their lives with integrity and fullness.
Consistent with the Preamble to the Ethical Principles of Psychologists, humanistic psychologists strongly support the ethical mandate to respect and protect human and civil rights. They do not knowingly participate in or condone unfair discriminatory practices. In addition, humanistic psychologists believe it is important to sensitize themselves and others to both the overt and hidden discriminatory practices in their culture and the world at large. Humanistic psychologists, consistent with their values of openness to others and the healing nature of personal empowerment, make efforts to expose themselves to an understanding of the experiences of non-dominant group members and attempt to provide a space for those members to communicate with the majority culture. In their respecting of ethical and civil rights, humanistic psychologists attend to the powerful and personally meaningful ways that society and culture are intricately embedded with (and sometimes even formative of) the person's experiential reality.
Principle A: Competence
Humanistic psychologists agree that psychologists should maintain the highest levels of competence in their work, recognize the boundaries of their expertise, and not practice beyond such boundaries. In addition, they believe that ongoing education is a vital component of personal and professional growth and competence. Since humanistic psychologists are aware of the limitations of life experiences and theoretical understandings based upon their particular sociocultural context, they actively strive to develop their competence in engaging members of groups from other sociocultural contexts. Humanistic psychologists, when possible, choose continuing education experiences that are consistent with humanistic ideals and principles with regard to diagnosis, therapy, and other professional issues. Due to their profound respect for the felt experience of others and their belief in the person being the expert on his or her felt realities, humanistic psychologists follow the Ethical Guidelines mandate of "exercising careful judgment" when working with persons or groups where "recognized professional standards do not yet exist" (APA, 1992, p. 1599). In these areas, they interpret the APA mandate to make "appropriate use of scientific, professional, technical, and administrative resources" (APA, 1992, p.1599) to mean that humanistic psychologists should critically evaluate whether the resources being used further the goals of humanistic practice.
Principle B: Integrity
Humanistic psychologists seek to promote integrity in the science, teaching, and practice of psychology through the humanistic value of reflecting critically on the effect of their own belief systems, values, needs, and limitations and the effect these have on their work. Further, humanistic psychologists also serve as valuable critics of more mainstream approaches by making explicit the hidden value assumptions in them. When critiquing these approaches, humanistic psychologists remain as honest, fair, and respectful as they are when dealing with any person or group. In addition, they do not make statements that are knowingly misleading, false, or deceptive.
With regard to empirical research, humanistic psychologists are aware that any research paradigm has value assumptions and biases inherent in the methodology. They tend to not accept anything as scientific until that phenomenon has been explored through the use of both traditional and alternative (narrative, phenomenological, qualitative, and so on) research paradigms. Humanistic psychologists are particularly cognizant of the ways that reductionistic approaches to psychology may result in psychologists making truth claims that, in actuality, are misleading or harmful to those persons being served. They also are cognizant of the ways such "scientific truths" may, due to the errors and biases inherent in reductionistic approaches, actually undermine the public's confidence in psychology and thereby deter the public's use of needed services.
Humanistic psychologists understand that issues of dual relationships are complex and difficult to sort out. On the one hand, most professional relationships are unavoidably complex and there are occasions where these complexities can be beneficial to those we serve. On the other hand, humanistic psychologists believe that improper and potentially harmful dual relationships should be avoided. When the relationship is experienced as improper by either the psychologist or the person being served, humanistic psychologists view the relationship as inappropriate. Humanistic psychologists continuously monitor their experience of clients, students, supervisees, and employees in order to ascertain when a relationship begins to feel improper. In addition to being open to feedback from any professional or group about when a relationship is improper, humanistic psychologists readily seek out the opinion of colleagues concerning situations about which they feel unsure. Such feedback is carefully and respectfully considered by the humanistic psychologist in determining the propriety of the relationship in question. When confronted with an unintended dual relationship, as sometimes happens in many communities and situations, humanistic psychologists clarify with themselves and their client, student, supervisee, or employee the nature of their role and responsibilities. Humanistic psychologists then monitor every decision they make concerning these persons to insure that it is a decision consistent with their primary moral and ethical responsibility to foster the growth and development of others.
Humanistic psychologists recognize that the persons who seek our services often feel profoundly vulnerable and threatened. They also understand that such persons may feel exploited by people in positions of power. Therefore, humanistic psychologists refrain from inappropriate, especially sexual involvements with current or former therapy clients in accordance with the Ethical Principles of Psychologists and laws.
Principle C: Professional and Scientific Responsibility
Humanistic psychology's emphasis on the importance of taking personal responsibility and flexibility in engaging each client in his or her uniqueness complies with the ethical principle of accepting "appropriate responsibility for their behavior, and adapting their methods to the needs of differing populations" (p. 1599). In addition to consulting with, referring to, or cooperating with "other professionals and institutions", humanistic psychologists consider the effect of such consultation and cooperation on the client's personal growth. For example, humanistic psychologists carefully consider both the potentially beneficial and the potentially damaging effects of psychotropic medications on the evolving therapeutic relationship when making a decision about referring for medication. In helping clients make decisions about psychoactive substances, humanistic psychologists are committed to the right of the client to choose freely whether to medicate with minimal coercion by others. As a general rule, humanistic psychologists do not believe that such medications (or any other invasive procedures) should ordinarily not be prescribed without an ongoing weekly therapeutic relationship with a primary therapist. Absent such a relationship, medication only can provide a chemical controlling of behaviors without potential for a transformation of suffering into a growth experience and may negatively effect the prospects for future success should such a relationship become available.
Principle D: Respect for People's Rights and Dignity
A central tenet of humanistic psychology is that all human fundamental rights, dignity, and worth must be respected. In this regard, humanistic psychologists believe that clients have the right to choose the type of therapy as well as whether to take psychotropic medications. Such respect is central to humanistic psychology's view of the client as the empowered consumer of psychological services. Since humanistic psychologists also respect the right to privacy, confidentiality, and self determination, situations may present a conflict between the client=s right to confidentiality and society=s right to know. In such circumstances, humanistic psychologists attempt to weigh, in good conscience and with an open mind, the existing literature on the advantages and disadvantages of each position as well as the relationship between these literatures and the particular client's life. While humanistic psychologists understand that they have the right to inform their clients that a disclosure of confidence may be beneficial to clients as well as to others who have concerns, humanistic psychologists understand that confidentiality is always the right of the person seeking our professional help. These understandings point humanistic psychologists to the importance of dialogue in determining when confidentiality will or will not be broken as well as the humanistic position that the breaking of professional confidence should be done only under extraordinary circumstances.
In addition, situations may present a conflict between the principle of self-determination and the principle of potential harm to self or others. Once again, the humanistic psychologist attempts to resolve such conflicts by weighing, in good conscience and with an open mind, the existing literature on the advantages and disadvantages associated with each position and their effects on a particular client=s life. These are often situations in which humanistic psychologists seek consultation from trusted humanistically-oriented colleagues. In these, as with all professional circumstances, careful, honest, and respectful consideration is given priority over routine, manualized, prescriptive, automatic, impulsive reactions.
Principle E: Concern for Others' Welfare
Humanistic psychologists seek to contribute to the welfare of those with whom they interact professionally. In so doing, they take particular pains to be sensitive to "real and ascribed differences in power between themselves and others" (APA, 1992, p. 1600); they attempt to empower others to a position of equality with psychologists. To do this, they support the client=s self-healing capabilities by empowering the client in the therapeutic relationship.
Consistent with feminist psychology's awareness raising as well as APA's emphasis on non-sexist language in professional writing, humanistic psychologists are particularly sensitive to the relation between language and power. For example, humanistic psychologists tend to prefer terms like "client" over "patient", "research co-participant" over "subject", and so on; the former terms imply greater equality and mutual expertise than the latter ones and sensitize the public to the consumer=s rights. Finally, humanistic psychologists stress qualities such as genuineness and openness and believe that any attempt to mislead others during or after professional relationships undermines the fundamental healing properties of the therapeutic encounter. Humanistic psychologists also believe that it is unethical to lead the public into thinking that the profession of psychology has reached agreement on singular, specific, empirically-based treatments for each "disorder." Due to their respect for the public, humanistic psychologists continue to sponsor discussion and education about these issues.
Principle F: Social Responsibility
Humanistic psychologists are aware of their responsibilities to the society in which they work and live. They apply and make public their knowledge of psychology in order to contribute to human welfare. They attempt to educate the public with regard to critically analyzing the values hidden in all psychological work. Humanistic psychologists recognize that law and social policies must be developed that serve the psychological interests of their clients and the general public. In other words, they recognize that, along with the privileges of being a humanistic psychologist, they have an obligation to participate in the political process of the development of society. Consistent with these principles, humanistic psychologists often contribute a portion of their professional time to activities with little or no monetary advantage.
The recommendations we have made for humanistic practice are based in principles that have evolved and developed from a longstanding community of practice, and most have been supported by empirical research. We believe that if therapists practice within these recommendations, then they will be practicing in an effective and ethical humanistic way. However, as recommendations, they do not meet all contingencies of practice. There may be occasions, or methods of practice, which depart in various ways from these recommendations, yet still may be considered effective and ethical given specific circumstances. Such instances must be evaluated on an individual, case-by-case basis.
Furthermore, these recommendations are not meant to be fixed for all time. This is a living document and will be revised to meet the needs of consumers, to profit from the experience of practitioners, and to be informed by further empirical research.
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 The "Recommended Practices and Principles for the Provision of Humanistic Psychosocial Services: Alternative To Mandated Practice and Treatment Guidelines" is a statement of policy of American Psychological Association Division 32, Humanistic Psychology. In promulgating these recommendations, the Division is not speaking for the American Psychological Association or for any other division or unit of the American Psychological Association.
Dr. Arthur Bohart, Chair of the Division 32 Task Force that wrote this document, is a Professor of Psychology at California State University Dominguez Hills, and an adjunct faculty member at Saybrook Graduate School. He may be contacted at the following address for further information: Department of Psychology, California State University Dominguez Hills, Carson, CA 90747; e-mail: firstname.lastname@example.org or email@example.com