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Persona Development and Training
PGDip in Psychological Wellbeing, Counselling and Psychotherapy
Module 4: Research Issues and Research Methods
Assignment: A Literature Review on a Counselling Related Topic
“The Client as the Agent of Change in
Counselling and Psychotherapy”
Word Count: 4398
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Introduction
Client-Centred Therapy, by definition, places the client at the centre of the counselling
process – “it is the client that knows what hurts, what directions to go, what problems
are crucial, what experiences have been deeply buried” (Rogers, 1967:11-12). Given
this, and my own personal commitment to the Person-Centred Approach, this
discussion will examine the roots of Person-Centred Counselling theory – Rogers’
(1942) assertion of individuals’ “drive toward growth, health and adjustment” (p.29),
his early appreciation of non-directivity (ibid.:126), and the necessity of clients’
perceptions of therapists’ ways of being (Rogers, 1957:227) – before critically
examining and evaluating the more recent cross-modality evidence in counselling and
psychotherapy literature of the “client as an agent of change” (Knight, 2018:no
pagination), and formulating suggestions on the implications for practice and research.
Lastly, and throughout the assignment, I shall reflect on how the deliberations,
recommendations, and conclusions of this assignment relate to my own personal and
professional experience.
My interest in the client’s role in therapy is fundamentally what brought me to study for
a Post-Graduate Diploma in Person-Centred Counselling. I have a passionate belief
that individuals are the expert in their own lives – “as no-one else can know how we
perceive, we are the best experts on ourselves” (Gross, 1992:905). This core
conviction led me from my undergraduate degree in psychology, to work in acute and
long-stay psychiatric settings in the late 1990s, to Mental Health Advocacy, and, six
years ago, to volunteering as a person-centred counsellor. The realisation, developed
over the 20 years of my professional life to-date, that I want to work in a field that
allows me to be the sort of practitioner that really listens to clients and supports them
where they are, is ever-more present for me, particularly as I approach the final months
of my PGDip. I (to quote Rogers’ assertion), “value the dignity and rights of the
individual sufficiently that I do not want to impose my way upon him” (Kirschenbaum,
1979:95), and this forms the basis of my professional interest in the client as the agent
of change in counselling and psychotherapy.
Carl Rogers’ theories regarding clients as agents of change
The idea that it is our clients who make change happen in the counselling room
arguably
underpins
Rogers’
original
concepts
of
Client-Centred
Therapy.
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Kirschenbaum (2012) postulated that Rogers defined the person-centred approach as
“a set of humanistic beliefs about human growth and development” (p.20) – a definition
which clearly iterates the importance of the actualising tendency, “the directional trend
which is evident in all organic and human life” (Rogers, 1967:351), as a foundational
concept in the modality (Bozarth, 1998:28). Indeed, Bohart (2013:98) is keen to point
out that, rather than the goal of therapy, clients’ actualisation is what makes therapy
work. For me, this philosophy links directly to trust, and trust in my client is trust in their
actualising tendency (Brodley, 1999:115-116). This has served me well through my
work as a counsellor; my belief that clients will find the best way for them, and that, in
doing so, any realisations and shifts in their thinking will be all the more meaningful.
Having said that, it is vital for me as a practitioner to be mindful not to become “hooked”
on clients’ acceptance or change (Mearns, 2003:18-21). That is, the idea that “if we
are to relate fully with our client in his growth process, we need to attend to all the
aspects of his experience” [author’s emphasis] (ibid.:19) not just the ones we, or they,
deem as positive. Indeed, the actualising tendency as Rogers theorised it, is “not
fundamentally moral” (Bohart, 2013, p.84); a person engaging in socially considered
“bad behaviour” is as much motivated by the actualising tendency as the “socially
good” person (Brodley, 1999, p.113).
The second fundamental notion of Rogers’ which appears to relate to the idea of the
client as the agent of change, is the concept of non-directivity. Described as personcentred counselling’s “unique contribution” (Cooper, O’Hara, Schmid & Bohart, 2013:
11) and “foundational” (Levitt, 2005:5), to be non-directive is arguably an attitude and
an ethical position, rather than a technique (Grant, 2004:162). In defining the nondirective approach, Rogers’ reported, “the counselor takes no responsibility for
directing the outcome of the process” (1942:115). However, it is said that Rogers did
acknowledge that, even with the aspiration of being non-directive, person-centred
therapists are focussed on facilitating the clients’ awareness and expression of all of
their feelings and that this, in itself, is an agenda (Kirschenbaum, 2012:24-25).
Patterson (2000) concurs, stating that, by its very nature, “therapy is an influencing
process” (p.182) and that the issue is rather whether the therapist’s motivation when
working with clients is consistent with the framework of the person-centred approach
– a fundamental faith in the actualising tendency (ibid.:183). I believe this position also
relates to the concept of “frame of reference” – “the subjective world of a person”
(Tudor and Merry, 2002:58). Personally, I believe, the actualising tendency, the
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concept of non-directivity, and the importance of remaining connected to the client’s
frame of reference are ideologically inseparable. To illustrate from a personal
experience: I remember the feeling I had as a client some years ago, when I visited a
person-centred counsellor with the hope of working through the difficult feelings I was
having as a new mum of two babies. I sat for 45 minutes, talking about how impossible
this felt for me, how tired I was, and how I was struggling with feelings of resentment
towards these two little people who depended on me completely. My counsellor’s
response: “what you’re experiencing is totally normal”. With that sentence, I felt the
whole of my experience being dismissed. I yearned for her to acknowledge my
distress; I certainly did not want this to be “normal”! This, to me, echoes the heart of
the person-centred approach and serves to drive my practice as I keep my clients’
reality, and my core belief in their agency, as my primary focus.
Rogers also sought to incorporate the client into his theory of what makes therapy
work when he wrote “The Necessary and Sufficient Conditions of Therapeutic
Personality Change” (1957). Specifically, for this assignment, Condition Six – “the
client perceives, to a minimal degree, the acceptance and empathy which the therapist
experiences for him” (ibid.:227) – which Whelton and Greenburg (2002) interpret as,
“it is not what the therapist does, but the client’s perception of what the therapist does,
that is crucial” (p.109). However, it would appear that the majority of literature assumes
that, provided the therapist can offer empathy, unconditional positive regard and
congruence, clients would automatically perceive that intent but, of course, this cannot
be taken for granted (Sanders and Wyatt, 2002a:xii). Toukmanian (2002:115)
recognises that perception is an essential part of Rogers’ theory of therapeutic change
but takes issue with what she sees as Rogers’ “general neglect of the role of the
dynamic interplay between the client and the therapist” (ibid.:117). This begs the
question of the paradox that exists and why little has been done to explore this
perspective (Mearns, 1997:144). Sanders
and Wyatt (2002b:9) somewhat
controversially suggest this has to do with a fundamental lack of trust in the client, and
that therapists’ appraisal is valued more highly than clients’ insight. My own thoughts
around this topic centre on my frustration with researchers, authors, and practitioners
in their prevalent misrepresentation of Rogers’ six conditions as three “core conditions”
(see Tudor, 2000). As therapists we tend to talk a lot about the client being the focus
of our work, but yet I believe that the dominant narrative fundamentally fails to reflect
this. I would argue that the Necessary and Sufficient Conditions, as Rogers
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hypothesised, must be considered as a whole – they are “dynamic... dialogic… [and]
relational” (Tudor, 2000:36) – and so to consider them as separate entities or, worse
still, rate three of them as “core” while essentially ignoring the other three (Mearns and
Thorne, 2000:88), is inaccurate at best and, at worse, skews the culture of personcentred therapy by perpetuating the myth that it is the therapist who is responsible for
clients’ processes. Instead, as a counsellor, I prefer to look to the roots of the modality:
“the only responsibility of the therapist is to initiate the receptive climate of the
relationship” (Bozarth, 1998:112).
Contemporary cross-modality research and literature regarding clients as
agents of change
As has been shown, Rogers’ theories point to clients doing much of the “work” in
therapy although, traditionally, the literature and research has failed to reflect this
(Bohart, 2011:102). In the last twenty-five years, however, there has been growing
recognition of clients as “active self-healers” (Bohart and Tallman, 1999, 2010a) and
it has been shown that so-called “client factors” may account for 40-87% of therapy
outcomes (see Bohart and Greaves Wade, 2013, for full discussion). Indeed, when we
consider that there are more than 400 different modalities of counselling which,
research and meta-analysis has consistently shown, are all about as effective as each
other (see Bohart and Tallman, 1999:27-33, for full discussion), it makes sense to
conclude that “change [in therapy] in primarily a product of the active client, who makes
the therapy work, regardless of what therapy he or she is using” (Bohart and Tallman,
1996:17-18). So exactly what does the literature say about how clients make therapy
work?
Some of the most convincing evidence that points towards clients as agents of change,
is found outside the therapy room: the human capacity for self-healing. Bohart and
Tallman (1996), in their paper “The Active Client: Therapy as Self-Help”, state that
“being active is human” (p.16), and that it is the human condition for all of us to search
for solutions to the issues we face – clearly mirroring Rogers’ theory of the actualising
tendency (Bohart and Tallman, 2010a:93). The research in favour of individuals’ ability
to self-heal is compelling. For example, in a Gallup poll of the US general population,
90% of people reported overcoming significant lifestyle, health or emotional issues in
the year prior to reporting, with the majority of support coming from friends, family, or
significant others (Gurin, 1990:50-52). In addition, although the evidence suggests that
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somewhere in the region of 60% of individuals are thought to have experienced a
traumatic event, research shows that only 5-10% go on to receive a diagnosis of posttraumatic stress disorder (Ozer, Best, Lipsey, Weiss, 2003:54). Human beings are
unarguably remarkably resilient. The evidence for clients as “active self-healers” is just
as supportive when we look at the data on “spontaneous recovery” (Bohart and
Tallman, 1999:36-37) and work on “early change” (Bohart and Tallman, 2010b:91-92).
For example, more than 60% of clients reported improvements in their situation
between the time they make their first appointment, to the time they first meet their
therapist (Miller, Duncan and Hubble, 1997, cited in Bohart and Tallman, 1999:37). In
addition, decade-long research involving clients who seem to be “early responders” to
therapy, indicates that 25% of clients fall into this bracket and that they not only to tend
have better outcomes, but they are also more likely to maintain their changes
(Lambert, 2007:5).
More evidence for how clients make therapy work comes from the literature on client
involvement and participation in counselling. Orlinsky, RØnnestad and Willutcki (2004),
for example, reviewed hundreds of studies of therapeutic processes and outcomes
between 1950 and 1992, and concluded that “the quality of the patient’s participation
in therapy appears to emerge as the most important determinant of outcome” (p.234).
That makes perfect sense to me as, fundamentally, clients (unless they are required
to go to counselling by a third party) have to make a choice as to whether or not to
seek out therapy, to physically be in the counselling room, and to psychologically
engage once they are there. Indeed, this is reflected throughout the BACP Ethical
Framework, particularly when it urges practitioners to consider the importance of
respecting clients, and to be mindful of appropriate relationship building (BACP,
2016a:1). Specifically, in relation to person-centred counselling, Thorne (1991) posits
that those who have the most to gain from this modality are “those who are strongly
motivated to face painful feelings and who are deeply committed to change” (p.131).
Certainly, it makes sense that for any psychological intervention to have a chance of
being effective, the client must be open to actively engaging in the process (Arnkoff,
Glass and Shapiro, 2002:335).
The vital importance of client participation in counselling is further developed as a
concept related to how clients make therapy work, when we look at the literature on
client agency and activity (Bohart and Tallman, 2010b:89). “Personal agency” (defined
as “the right to use one’s own power and authority to act for oneself” (BACP, 2016b:4))
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is referenced in the Ethical Framework as an area that requires “competent
attentiveness” by practitioners (BACP, 2016a:3). Certainly,
“The evidence shows that clients play an active role in shaping
the therapy process… creatively working to get what thay want
and need, protecting themselves when necessary and
supporting the therapist when they think they need it” (Bohart
and Tallman, 2010a:114)
In terms of research evidence for clients’ experiences of agency, a study by Hoener,
Stiles, Luka and Gordon (2012), using in-depth semi-structured interviews with 11
participants (p.64), found that the ability of clients to make and enact choices about
their therapy (to have agency) was highly valued, and had a positive effect on the
perceived outcomes of their counselling (p.78-79). Furthermore, Mackrill (2008), from
his diary study, posits that clients’ “pre-therapeutic strategies” are key to how they
work in the counselling room (p.451), and that the incorporation of these may be
significant for the outcome of their therapy (p.452). Indeed, Levitt and Rennie (2004 –
see chapter for full discussion), assert that the research suggests not only do clients
direct the counsellor in ways that they perceive will be advantageous, but they also
internally revise unhelpful input in order to enhance therapeutic outcomes (pp.310311). Moreover, even in long-term therapy, evidence shows that clients are adept at
hiding that they do not want their counsellors to know, and that (in parallel with this)
therapists are not very accurate at predicting what clients are withholding (Hill,
Thompson, Cogar and Denman III, 1993:283). Finally, in the process of therapeutic
endings, research shows that clients demonstrate a significant amount of agency
(Råbu and Haavind, 2018:223), as a way of exercising their own power and “coming
to terms with experiences that could otherwise stay troublesome” (ibid.:239). All of
this evidence indicates that clients are, undeniably, creative agents of change in the
therapy room, even though “virtually no theory of psychotherapy grants clients
capacity for generative thinking” (Bohart & Tallman, 2010a:111). On reflection, I like
to believe I am attentive to clients’ procreative ideas, and that this relates directly to
my faith in the actualising tendency. What good would my strategies be for others,
they are mine; far better for me to support clients to generate their own ways of
thinking, their own ways forward.
The final area to be examined when considering clients as agents of change in
counselling and psychotherapy takes us, again, back to the roots of Rogerian therapy:
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clients’ perspectives on the therapeutic relationship, and the processes that occur
within it. As Barrett-Lennard (1998) asserts “the relationship as experienced by the
client will be most crucially related to outcome” (p.80). Metcalf, Thomas, Duncan, Miller
and Hubble (1996) concur by stating that “client perceptions of the [therapeutic]
relationship are the most consistent predictor of improvement” (p.335). Furthermore,
when clients reported on their perception of a positive therapeutic alliance, research
found they focussed less on the individual attitudes of the counsellor, and more on
their own awareness of the relationship as being one in which they felt “at ease”
(Bachelor, 1995:331-332). More recently, Swift, Tompkins and Parkin (2017) looked
at clients’ perspectives on “helpful and hindering events” in therapy and concluded
that clients often interpret the same sorts of responses from their counsellor as either
helpful or unhelpful, and what is important is the context (p.1553-1554). In addition, it
would appear that a rigidly non-directive approach is perceived by clients as being as
unhelpful as a rigidly directive one (Cooper, 2010:186). Lastly, perhaps what is most
interesting when we talk about perception, is the apparent disparity between the
accounts of therapists and their clients when relating a therapeutic encounter (see
McLeod, 1990:75-78 for a full discussion). I can certainly relate to times when I have
left a session thinking that one particular moment was especially powerful, only to have
my client return the following week recounting that they felt a totally different moment
has left an impression on them! This reinforces the proposition that “we can only know
how therapy works by asking the client” (Bonsmann, 2010:42).
Implications for practice and research
Some might say that the aforementioned literature, particularly that which
demonstrates clients as “active self-healers” (eg Bohart and Tallman, 1999), reflects
a view that counselling and psychotherapy is superfluous. Indeed, it is true to say that
the catalyst for constructive change comes in many guises, and that this may not
necessarily include a formalised therapeutic relationship (Bozarth, 1998:41-42). As
Bozarth (ibid.) states, when considering Rogers’ (1957) “Necessary and Sufficient
Conditions”, “the remarkable resilience of humans in terms of the actualizing tendency
leads me to conclude that the conditions may not necessarily be necessary”. Having
said that, the evidence is that therapy provides two things which clients may not have
access to in their everyday lives: a focussed supportive relationship, and an
emotionally safe time and space, with and in which to examine their own issues
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(Bohart and Tallman, 2010b:103). The vast majority of the individuals I see for Initial
Assessment, for example, when asked what they would like to get out of counselling,
say something along the lines of, “I’d like space to talk about what I’m going through,
with someone who doesn’t know me”. This emphasises Bohart and Tallman’s (1999)
assertion that therapists need to pay attention to the relationship between themselves
and their client in order to “promote a climate within which clients can feel safe and
prized, and begin to trust and use their self-healing capacities” (pp.19-20).
Furthermore, bearing in mind Hill et al.’s (1993) work on “covert processes”, we may
posit that it is crucial to check out with clients how they are experiencing therapy,
suggesting the importance of being open to “metacommunication” within the clientcounsellor relationship (see Rennie, 1998:89-110); where metacommunication is
defined as “a means of examining processes underlying the overt interaction…
[between counsellors and their clients]… which caused impasses in the therapeutic
relationship” (Yerushalmi, 2017:347), and is a way of furthering mutuality in the
counselling room (ibid.: 359-360). My concern as a practitioner would be how to tap
into this is a person-centred way – how to offer my observations to clients without it
detracting from their process. Perhaps proffering it as a suggestion, or a hunch, that
there is something going on, asking clients, as Rennie (1998) suggests: “when I put
that question to you, how do you find yourself reacting to it?” or “What is that like for
you [to hear me say that]?” (p.98), in a way that would be gentle enough to remain
with the client, but to also invite them to feedback on their unspoken notions, potentially
offering them an opportunity, should they wish to take it, to further mutuality in our
relationship.
This notion of clients as agents of change, arguably enhances the importance of the
person-centred focus on clients’ “frame of reference”. Indeed, research by Duncan and
Moynihan (1994), examining 30 years of client-focussed outcome research, provided
not only “a compelling argument for allowing the client to direct the psychotherapeutic
process” (p.294), but also strongly suggested a more deliberate utilisation by the
therapist of the client’s frame of reference (ibid.:300). These findings lend weight to
the person-centred way of being, reinforcing Rogers’ (1957) hypothesis of the Six
Conditions as “sufficient” (see Bozarth, 1998:35-42), and subsequently mirroring my
experience, alluded to earlier in this assignment, whereby my counsellor appeared to
disregard the strength of my emotion, discount my “frame of reference”, as to her my
experiences sounded “normal”.
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From the evidence considered, it is clear that “it is not so much what therapists say,
but how they say it that’s important” [authors’ original emphasis] (Bohart and Tallman,
2010a:122), and that the goal is to relate to clients, at all times, in a sensitive,
supportive, respectful way, which strives to honour clients’ capabilities and selfjudgement (ibid.) – that is, to be truly client-centred. However, within that, Bohart
(2011) is also keen to stress that, even in person-centred therapy, the power
distribution is not equal and that “most clients view the therapist as an expert” (p.107)
– see Proctor (2017:107-129) for full examination of power in the person-centred
therapeutic relationship. Nevertheless, as research has shown, even if clients publicly
defer, the do not necessarily privately capitulate (Levitt and Rennie, 2004:311). Thus,
I believe that, as a person-centred counsellor, I can take comfort in the fact that my
clients potentially exemplify more agency than they themselves may even be aware
of. Accordingly, even though I did not challenge my counsellor in her seemingly
misguided attempt to “normalise” my experience, I did not return to see her again, but
instead sought out someone who I felt was more attuned with my emotions. As a
therapist, I am mindful of my professional responsibility to be aware of my clients’
personal agency (BACP, 2016a:3, 5, 7), and to listen to what my clients are not saying.
Indeed, the research shows that therapy is most effective when it supports and
nurtures client involvement and participation (Orlinsky et al., 2004:234), and as
counsellors we can facilitate that by demonstrating our active listening and privileging
client experience (both in and out of the therapy room) (Wampold, 2010:116-117).
In terms of implications for research, it is imperative to remember that correlation does
not equal causation (Cooper, 2008:61-62). Demonstrating that there is a link between
client factors and positive outcomes in therapy does not necessary prove that the
former causes the latter, merely that there is a connection (ibid.). We may hypothesise
that clients who are, for example, more intuitive, or more intelligent, are more likely to
engage in therapy, and that this makes the difference in their outcomes. Yet, this would
also be evidence of the client as an agent of change – regardless of how they do it, it
is the client who makes therapy happen. Thus, if we are to accept that clients are
agents of change in the counselling relationship, then more research is needed to
ascertain exactly how clients do this (Bohart and Greaves Wade, 2013:256). Wilkins
and Mitchell-Williams (2002) urge for focus on research that is genuinely personcentred as “there is [currently] little research which conforms fully to person-centred
principals” (p.291). Instead, they suggest that an emphasis be placed on research that
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is collaborative, in order to reach an understanding of what is important to clients
(ibid.:300-301). Indeed, there is evidence to suggest that established outcome
measures fail to reflect core person-centred goals and concepts, and instead are
historically “akin to weighing oranges with thermometers” (Levitt, Stanley, Frankel and
Raina, 2005:126). Bohart (2011) concurs, stating that when one reads clients’
descriptions of therapy from their own perspective, it’s like entering “a different
universe from the one described in most therapy books” (p.109). Essentially, what is
missing from the vast majority of psychotherapy literature are clients’ voices (Gabbard
and Freedman, 2006:184). The issue lies, perhaps, in the conflict between the
emphasis on evidence, statistics and objectively rigorous research, and the reality that,
for person-centred practitioners, results that generalise our client population tell us
very little about what might be of benefit to the individual client in our room (Cooper,
2010:183). Any methods employed to assess how clients make therapy work, need to
take into account that when done sensitively, within the context of a good therapeutic
relationship, such endeavours have the potential to empower clients and “and foster
collaborative practice” (Solstad, Castonguay and Moltu, 2017:11). Furthermore, there
is recognition that the very act of reflecting on the therapy can enhance a client’s
feelings of agency and contribute to their process (Rennie, 2010:43). It is clear that
more research in this area is needed, perhaps combining a quantitative measurement,
such as the Therapeutic Agency Inventory (Huber, Nikendei, Enrenthal, Schaunburg,
Mander and Donger, 2018), with more person-centred theory-congruent outcome
measures such as recordings of sessions, and the diary/semi-structured interviews of
grounded theory studies (as per Rennie’s work – documented in Rennie, 2002).
Focusing on clients’ experiences of their perceptions of agency, their counsellor, the
relationship, and the events in the counselling room is the only way to begin to know
how clients make therapy work.
Conclusion
This assignment has examined the literature with regards to the client as the agent of
change in counselling and psychotherapy, with an emphasis on the person-centred
approach. It has focused firstly on the work of Carl Rogers, whose theories clearly
centre on clients as primary agents in the therapeutic process, before also looking at
contemporary cross-modality research, ethical considerations, and the real-world
implications for practice and further research.
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Personally, my growing awareness of individuals as agents of change in their lives has
served to enhance my commitment to facilitating client self-determination, and my
professional allegiance to the person-centred approach. Towards the end of his
career, Rogers (1978) summed up this attitude as,
“…a conscious renunciation and avoidance by the therapist of
all control over, or decision-making for, the client. It is the
facilitation of self-ownership by the client and the strategies by
which this can be achieved; the placing of the locus of decision
making and the responsibility for the effects of these decisions”
(p.14).
Indeed, it is clear to me that, as a therapist, if I subscribe to Rogers’ foundational
concepts of the actualising tendency, non-directivity, and client perception (as being
“necessary and sufficient” – Rogers, 1957), then consequently I must also concede
that it is clients who make therapy work, that they are the agents of change.
Conversely, if I am to accept the overwhelming evidence that clients are the agents of
change in counselling and psychotherapy, then it naturally lends weight to the personcentred theories of the actualising tendency, non-directivity, and “perception” as a
condition of therapeutic change as “not necessarily necessary but always sufficient”
(Bozarth, 1998:42). What is apparent is that more theoretically-congruent research is
needed to examine and uncover exactly how clients make person-centred therapy
work.
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