Theoretical Comparison Paper
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Theoretical Comparison Paper
Teresa D. Sawatzky
University of Calgary
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Theoretical Comparison Paper
Theories are systems of ideas that, in the most general sense, try to do two things. First
they attempt to make sense of existing information. Data and observations from the world
around us are collected, analyzed and condensed into a set of explanations. Second, theories
use the explanations of existing phenomena to anticipate or offer tentative predictions of future
observations (Magnusson, 2006, The Nature of Theory, para. 1).
This essay will critically compare and contrast two different theories of counselling and
client change: Behavior Therapy (BT) and Person-Centered Therapy (PC). It will examine how
these selected theories are similar and different in respect to the following four elements of a
good theory: philosophical element, descriptive element, prescriptive element and evaluative
element.
Philosophical
Every theory, and every theoretician, holds a core set of unprovable assumptions.
These working assumptions serve as a conceptual guide to all aspects of theory. The following
section describes the similarities and differences between BT and PC (Magnusson, 2006, The
Philosophical Element section, para. 1).
Similarities
The primary goal of both PC and BT is to help people with psychological problems. The
implicit assumption is that psychological distress is bad and therefore should be eliminated or at
least lessened. However the approaches of BT’s third generation therapies, Acceptance
Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT), are based on a radically
different assumption that psychological distress is assumed to be an inevitable part of life which
means that they cannot be completely avoided or eliminated. Not accepting this premise and
fighting it may actually contribute to a person’s suffering (Wilson, 2011). Both PC and BT have
an optimistic view of human nature and fundamentally assume that people are basically good
and that people can change even when they are deeply disturbed.
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Some additional similarities across the two approaches include an emphasis on client
resilience and strength and a belief that clients know what they need. Also both approaches
focus on validating clients’ experience and knowledge and fostering client autonomy as well as
the provision of an egalitarian relationship and a preference to work outside the framework of a
pathological model. (Watson, 2006)
Differences
There are a number of philosophical differences between BT and PC. BT is
deterministic, directive and action oriented emphasizing outcome and change. In contrast PC is
more process oriented than goal oriented. (Watson, 2006) Also, BT tends to concentrate on
maladaptive behavior itself, rather than on some presumed underlying cause. Within PC
purpose rather than cause is the decisive dynamic and will concentrate, in a humanistic fashion,
on the person over the problem (Raskin, Rogers & Witty, 2011).
BT assumes that maladaptive behaviors are, to a considerable degree, acquired through
learning, the same way that any behavior is learned (Wilson, 2011). In contrast, PC would
argue that behavioral changes occur through internal factors. PC is basically phenomenological
in character and relies heavily upon the concept of the self as an explanatory construct (Raskin
et al., 2011). PC assumes all living organisms are motivated by an inherent tendency to
maintain and enhance themselves. The actualizing tendency is the one motivating force in a
client and this actualizing tendency functions continually and holistically throughout all
subsystems of the organism. (Raskin et al., 2011) What crucially distinguishes PC theory from
more deterministic approaches is the assumption that it is possible to go beyond our
conditioning. The democratic non-authoritarian values inherent in this theory result in an
approach that honors the person’s right to self determination and psychological freedom (Raskin
et al., 2011).
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Descriptive
One of the central purposes of a theory is to explain existing information and
phenomena which is known as the descriptive element (Magnusson, 2006, The Descriptive
Element section, para. 1). In the following section this essay describes the gaps in theory. If
there are significant gaps in descriptive theory then it loses its utility. Also, the comprehensive
nature of the theories are discussed in term of disorders covered and the degree of diversity
addressed. Finally we will look at the theories in relation to manual based treatments to critique
the issue of parsimony and cohesiveness.
Gaps in theory
Both PC and BT therapists avoid the hidden or unknown and aim to enhance the life
functioning and self experience of clients. Behaviorism is a pragmatic approach that is
concerned only with how a behavior manifests itself in the present environment (Wilson, 2011).
PC focuses most heavily on the present and clients can talk about whatever they want to that is
important to them at the current moment (Raskin et al., 2011). It can be seen as a limitation and
a weakness for both theories that they only take into context present factors leaving a void in
addressing potentially critical past issues.
In addition PC therapists state that the three core conditions of congruence,
unconditional positive regard and empathy are necessary and sufficient (Raskin et al., 2011).
By prescribing the same set of conditions for all patients it is paradoxically lacking in case
specificity. A warm, unconditionally accepting therapeutic relationship is not always universally
helpful and may prove to be harmful in certain cases (Silberschatz, 2007).
BT Spectrum of Disorders
BT provides treatment for a vast number of disorders and conditions which makes this
theory highly comprehensive in whom and what can be treated. BT addresses a broad
comprehensive range of disorders such as anxiety, panic disorder, OCD, PTSD, depression,
eating and weight disorders, obesity, schizophrenia, and childhood disorders. Behaviorism is
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often used as a training strategy for the severely mentally handicapped, such as the mentally
retarded, autistic or mentally ill (Wilson, 2011).
BT is also applied to such diverse health related problems such as tension headaches,
different forms of pain, asthma, epilepsy, sleep disorders and nausea etc. BT can be used to
treat a full range of psychological disorders in different populations and has broad applicability
to problems in education, medicine and community living. BT also includes the realm of
behavioral medicine specifically in the prevention and treatment of cardiovascular disease
(Wilson, 2011).
PC Spectrum of Disorders
Although it may not be as rich or comprehensive in the number of disorders that are
addressed, PC is still applicable for treatment of several types of disorders. PC treats the
psychotic, developmentally disabled, panic disorders, bulimia, and also helps people looking
strictly for a personal growth experience. Ideally it is applicable generally to anyone. PC has
worked successfully with a myriad of clients with problems in living including those with
psychogenic, biogenic and sociogenic origins. There has been a stereotype of PC as only
being applicable to “less severe” clients, but in reality there has been noted success with PC in
addressing disorders such as schizophrenia (Raskin et al., 2011).
BT and Diversity
Not only can BT address a myriad of different disorders it recognizes the need for
addressing diversity in a globalizing world. BT has been shown to be effective with diverse
patient populations including disadvantaged minority groups. There is now evidence that
cognitive and behavioral treatments for anxiety disorders and depression are effective in helping
minority group members in community based treatment settings (Wilson, 2011).
Demonstrating the relevance of evidence based psychological therapy for members of minority
groups is a research priority given that these individuals tend to be underrepresented in
specialized university and medical school settings. As Tanaka-Matsumi notes on p.267,
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“Globalization will encourage training of multicultural mental health
professionals who can apply universally applicable principles of
behavior
change
and
implement
culturally
specific
treatment.
Functional analysis is a flexible and individualized method that can
identify culture relevant content in CBT for diverse clients” (2011).
PC and Diversity
In treatment, PC does not assume difference except as the client asserts how he or she
experiences self as different. PC has addressed conflict resolution not only within the office
setting, but it has also branched out to address a diverse world in need of peace. It has
contributed to reduction of racial and political tensions by addressing groups and nations in
conflict. This has occurred with parties from Northern Ireland, South Africa, and Central
America (Raskin et al., 2011). Also, the Association for the Development of the PersonCentered Approach (ADPCA) is composed of persons in many different occupations; educators,
nurses, psychologists, artists, and business consultants all who are a part of this growing
community of persons interested in the potential of the approach (Raskin et al., 2011). PC
therapy can also be extended beyond the office in play therapy, group therapy, leadership and
administration. PC has reached more than 30 counties and has been translated to 12
languages (Corey, 2009).
Manual Based Treatments
The use of manual based treatments by a BT therapist helps the process to be broken
down into steps which contributes to making the theory parsimonious and in turn increases its
utility and makes its concepts operational. It is easier to measure concepts that are clearly
defined and specific. There are now evidence based CBT treatment manuals for a variety of
clinical disorders including anxiety disorders, depression and eating disorders. It describes a
limited and set number of techniques for treating a specific clinical disorder and makes therapy
more consistent and more widely available. Additionally, it is easier for therapists to learn
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specific treatments and for supervisors to monitor their trainee’s expertise. They can also
greatly reduce the number of sessions needed in therapy (Wilson, 2011).
PC therapists would state that because both the therapist and the client are unique
persons, the relationship that develops between them which is unique and unpredictable cannot
be prescribed by a treatment manual (Raskin et al., 2011). The very concept of following a
manual is contrary to the basic nature of PC. However, manual based treatments can increase
the personal element of understanding as an individual needs to understand the descriptions
provided by a theory before the ability of the theory to account for existing data can be
evaluated (Magnusson, 2006, The Descriptive Element, para. 3).
Prescriptive
In order for a theory to be helpful they must give us some guidance regarding what and
how to change. (Magnusson, 2006, The Prescriptive Element section, para. 1) This section will
address what both PC and BT would prescribe in order to enact change in a client
Assessment
The BT therapist would identify and understand the clients presenting problem. There
are a number of techniques used to assess and identify the problem of a client. These
techniques include functional analysis, interviews, guided imagery, role-play, self monitoring,
reports and ratings, observations, and physiological methods (Wilson, 2011). In PC, the therapy
starts immediately upon first contact. In the first interview the therapist would not assess the
patient or take history into account. They wouldn’t diagnose, evaluate whether the patient was
treatable or estimate the length of treatment (Raskin et al., 2011).
A strong therapeutic alliance is essential for effective BT, yet nonetheless, the
therapeutic alliance does not mediate treatment outcome. It is necessary, but not sufficient.
Treatment methods account for more variance than measures of therapeutic alliance. If the
client feels trusting and warm toward the therapist, this generally will facilitate following
treatment regimen, will be associated with higher expectations of improvement, and other
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generally favorable factors (Wilson, 2011). This is similar for PC in that it is an essential
component that the client perceive the conditions offered by the therapist (Raskin et al., 2011).
However, according to a PC therapist, a congruent, nondirective client-centered therapist who is
experiencing some level of empathic, positive regard from within the frame of reference of the
client is a different phenomenon from the therapist who deliberately sets out to establish a
therapeutic alliance in order to establish bonds, tasks and goals (Raskin et al., 2011).
Diagnosis
The BT therapist would then make a diagnosis based on the assessments completed.
The PC therapist will dispute the fact that advice, suggestion, teaching or diagnosis is
necessary. Proponents of PC see problems, disorders and diagnoses as constructs generated
by processes of social and political influence in the domains of psychiatry, pharmaceuticals, and
third-party payers as much as by bona fide science. Therefore they see diagnosis as
unnecessary and a waste of time. PC considers that a diagnosis of the psychological dynamics
is not only unnecessary but in some ways harmful... There is a concern that the process of
making a diagnosis leads to an inequality in the power dynamic between counsellor and client.
(Raskin et al., 2011).
Goals
The next step would be to negotiate goals with the client. The BT therapist would make
sure the client is actively engaged in the process of choosing a target behavior (goal) that is
realistic, specific and measurable to maintain objectivity and validity. Behaviorism generates
interventions based on objective measurements of observed behaviors. The learning that
characterizes BT is carefully structured (Wilson, 2011).
For PC, the external view is meaningless in the therapy process since the only function
of the therapist is to facilitate the client’s actualizing process. PC therapists trust that individuals
and groups are fully capable of articulating and pursuing their own goals. The implicit practicality
for therapy is that the individual must be free to follow their own way, in their own direction and
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at their own pace (Raskin et al., 2011). A PC therapist relates as an equal to the client, and
trusts and respects the client’s perceptions as the authority about themselves. PC holds to the
principle of nondirectiveness which is contrary to the directive nature of BT. This challenges the
BT assumption of therapist as expert and that "the counselor knows best" (Raskin et al., 2011).
Specific Treatments
Behavioral Therapy. BT offers a wide range of different treatment methods and
attempts to tailor the treatment to each individual’s unique problem. One such intervention
would be an Imagery Based Technique called Systematic Desensitization that was developed
by Joseph Wolfe and was designed for clients with phobias (Wilson, 2011). It is probable that
some form of real life exposure will be a central part of therapy. The techniques do not focus on
clients achieving insights into their behavior but rather the focus is just on changing the behavior
itself. Learning processes such as token reinforcement programs (operant conditioning) and
classical conditioning are also used and have been highly successful and efficacious. These
techniques are known as the first wave of BT and do not involve cognitive processes (Wilson,
2011).
In Social-Cognitive theory the influence of environmental events on behavior is largely
determined by cognitive processes governing how environmental processes are perceived and
how they are interpreted. Strongly influenced by the social cognitive model the clinical practice
of BT has increasingly included cognitive methods, especially those described by Beck
(Cognitive Therapy). A primary focus of both cognitive and behavioral techniques (Cognitive
Behavioral Theory) is to change the cognitive processes viewed as essential to therapeutic
success. This is referred to as the second wave of BT (Wilson, 2011).
The third wave of BT includes Acceptance and Commitment Therapy (ACT) and
Dialectical Behavior Therapy (DBT). These are based on a radically different assumption:
psychological pain and distress are assumed to be an inevitable, ubiquitous part of life which
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means that they cannot be completely avoided or eliminated. Not accepting this premise and
fighting it may actually contribute to a person’s pain and suffering (Wilson, 2011).
BT also uses other diverse interventions such as: aversion therapy, modeling,
biofeedback, cognitive restructuring, assertiveness and social skills training, real life
performance based techniques and self control procedures (Wilson, 2011).
Person-Centered Therapy. The PC view holds that there is incongruence within the
client, which is a discrepancy between self-perception and experience in reality. It is the
person’s expression of self and his or her relation between self and disorder, self and
environment that they seek to understand. Within PC, the use of self is seen as an instrument
of change (Raskin et al., 2011).
There are not any techniques used or treatment planning. The only necessary and
sufficient element is the therapeutic relationship exhibiting core conditions of congruence,
unconditional positive regard and empathy that function holistically as a gestalt. Through the
therapist’s attitude of genuine caring, respect, acceptance, and understanding, clients become
less defensive and more open to their experience and facilitate their personal growth. There are
three other conditions in addition to these. They include the fact that the client and therapist
must be in psychological contact, the client must be experiencing some anxiety, vulnerability or
incongruence (preconditions) and the client must perceive the conditions offered by the
therapist (essential) (Raskin et al.,, 2011). When the client perceives the therapist’s empathic
understanding and unconditional positive regard, the actualizing tendency of the client is
promoted.
The client’s work in defining the problem is the therapy within PC. The therapy is the
diagnosis and this diagnosis is a process that goes on in the experience of the client, not in the
intellect of the clinician. In PC, the client reacts to the environment as it is perceived but the
therapist puts confidence in the process of therapy over time to yield more self accepting and
accurate self appraisals on the part of the client rather than telling the client how to think
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because his or her thinking is “clearly wrong” such as in cognitive restructuring (Raskin et al.,
2011). PC would prescribe play therapy, client centered group process, classroom teachings
and the intensive group.
Reassessment
In BT, the client’s progress is reevaluated and compared from the initial baseline
assessment. There is no need to assess/reassess with PC as this would potentially put on the
client “a condition” of worth of whether they have “achieved” their goals or not.
Evaluative
The final theoretical element to consider when conducting a critical review of a theory is
the degree to which the theoretical constructs may be tested (Magnusson, 2006, The Evaluative
Element section, para. 1). The following paragraphs will address the evaluative components
along with limitations pertaining to each theory.
There have been studies that show evidence that BT is successful with disorders such
as Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, Schizophrenia, Childhood
Disorders, Panic Disorder and Bulimia Nervosa (Wilson, 2011). It is important to point out that
effectiveness studies are beginning to show that that the results of the efficacy studies do
generalize to routine clinical practice. Evidence for third wave forms of BT are gradually
emerging. DBT for borderline personality disorder clearly enjoys empirical support but the
evidence on ACT is promising albeit still at a rudimentary stage (Wilson, 2011).
BT Methods and Efficacy
Findings suggest that CBT represents one of the strongest, if not the strongest,
theoretical emphases today. The efficacy and effectiveness of BT has been studied more
intensely than in any other form of psychological treatment. In selecting treatment techniques
BT relies heavily on empirical evidence about the efficacy of that technique applied to the
particular problem (Wilson, 2011).
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Qualitative. BT utilizes single case experimental designs which are important because
they enable cause and effect relationships to be drawn between treatment outcomes in the
individual case. Limitations include the inability to examine the interaction of subject variables
with specific treatment effects and difficulty in generalizing findings to other cases (Wilson,
2011).
Quantitative. BT involves a commitment to the scientific method using experiments that
allow rigorous evaluation of specific methods applied to particular problems instead of global
assessment of ill- defined procedures applied to heterogeneous problems. Advantages include
the use of multiple objective measures of outcome, the selection of homogeneous subject
samples and the freedom to randomly assign subjects to experimental and control groups under
tightly controlled situations. One limitation would include the possibility that findings in the lab
won’t generalize to real life situations (Wilson, 2011).
Comparative research strategy. This research is directed toward determining whether
some therapeutic techniques are superior to others. However there are few well designed head
to head comparisons with other psychological therapies. With rare exceptions, alternative
psychological treatments have not been submitted to rigorous empirical evaluations. The
evidence as unsatisfactory as it is indicates that behavior therapy is more effective than
psychoanalytic and other verbal psychotherapies (Wilson, 2011).
Depression. Several well-controlled treatment outcome studies have shown that CBT is
an effective treatment for depression, including severe depression. It appears to be as effective
as antidepressant medication and more effective over the long term because when medication
is discontinued, patients often relapse rapidly. CBT is effective not just in research conducted at
major universities but also in routine clinical practice and with minority groups who are typically
underserved. CT was found to be no more effective than the behavioral component of the full
treatment package and when severely depressed were analyzed, BT proved more effective than
CT (Wilson, 2011). However many researchers have argued persuasively that in addition to
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other limitations, these studies do not take therapist allegiance into account. They suggest for
example, that the CBT therapists in these studies (and the researchers) had a level of training
and commitment to CBT that was greater than the training and commitment of the therapists in
the comparison groups and that when these differences in therapist allegiance are controlled
statistically, the differences in treatment approaches all but disappear (Kirschenbaum and
Jourdan, 2005).
American Psychological Association. In an evaluation of the evidence for different
psychological treatments Division 12 of the APA established criteria for judging treatments as
“empirically supported”. BT dominates the list of what have been called empirically supported
therapies (EST) (Wilson, 2011). However, PC advocates would point out that at the end of the
20th century, the APA Division of Psychotherapy (Division 29) created a panel to summarize the
research on effective therapy relationships. This task force consisted of 10 committee members
(none were PC) was in part a response to the growing movement especially in the United
States, toward ‘empirically supported treatments’. Federal funding of research on
psychotherapy was moving strongly toward identifying those treatment approaches that were
shown empirically to be effective, especially with patients with specific diagnoses like anxiety,
depression etc (Kirschenbaum and Jourdan, 2005). The conceptual basis of the EST
movement is embedded in the medical model of psychotherapy and thus favors treatments
more closely aligned with the medical model such as behavioral and cognitive treatments.
Although apparently harmless, PC sees the EST movement as having immense detrimental
effects on the science and practice of psychotherapy, as it legitimates the medical model of
psychotherapy when in fact treatments are actually equally effective (Wampold, 2001).
PC Method and Efficacy
To be a PC therapist is to represent oneself as a professional who is successful at
helping. If one fails to help, there is an ethical responsibility to give the client an accounting for
the failure (Brodley, 1974). PC has shown evidence for successfully treating schizophrenia and
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for its validating some of their key concepts as congruence and self-determination. Large scale
quantitatively focused studies have been lacking in recent decades even though theoretical,
philosophical, ethical and naturalistic qualitative (subjective) studies have flourished (Raskin et
al., 2011). The World Association for Person Centered and Experiential Psychotherapy and
Counseling (WAPCEPC) consists of psychotherapists, researchers and theorists from many
countries who actively seek to reassert the revolutionary nature of a PC approach. WAPCEPC
has launched the peer reviewed journal Person Centered and Experiential Psychotherapy
(PCEP), which publishes empirical, qualitative and theoretical articles of broad interest to
humanistic practitioners and researchers (Raskin et al., 2011).
Common Factors Research. PC has received strong support from common factors
research efforts. Decades of meta analyses strongly support the Dodo Bird Effect and refute
the idea that specific schools of therapy and their specific techniques are more important than
the common factors. Lamberts 1992 study estimated that the variance in outcome attributed to
therapeutic factors was 30%; techniques was 15%; placebo or expectancy effects was 15%;
and client variables was 40%. Common factors research has yielded strong, very consistent
findings supportive of the therapeutic relationship as a principal source of therapeutic change
(Raskin et al., 2011). Such research has also found that techniques, though not negligible,
contribute much less to the actual outcome. Bozarth (2002) opposes the idea that specific
techniques (BT/CBT most often) are crucial to therapeutic success. The specificity myth (the
belief that specific disorders require specific treatments) is fictitious. There is resistance to
these findings because new schools of thought and accompanying techniques produce income
and status in the field of psychotherapy, leading to a proliferation of treatments for an ongoing
proliferation of disorders on which various practitioners announce themselves as experts
(Raskin et al., 2011).
Core Conditions. The Client Centered approach can confidently claim evidentiary
support for the core conditions and for the impact on outcome when the client’s perceptions of
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the conditions are utilized as an outcome measure (Raskin et al., 2011). It needs to be taken
into account that the studies of only one of the core conditions do not test Roger’s client
centered model of therapy; rather, all six of the necessary and sufficient conditions must be
accounted for in the research design (Watson, 1984). Even so, positive correlations between
outcome and empathy and between outcome and positive regard are partially supportive of the
model. Most recently Elliott and Freire (2008; Elliott, 2002) conducted and expanded metaanalysis of humanistic therapies (including PC) that assessed nearly 180 outcome studies.
Their analyses examined 203 client samples from 191 studies, 14, 000 people overall. Elliott
and Freire conclude that their meta-analytic studies show strong support for PC even when
compared to CBT. However, often a manual is used for research, which in essence is
antithetical to PC and therefore does not fully represent its theory.
Conclusion
It is important when choosing theories to critically analyze how they measure up to the
philosophical, descriptive, prescriptive and evaluative criteria as this will guide practice. New
counselors would certainly benefit from a theory such as BT. It is simple to follow due to
manual based treatments for common disorders and it enjoys the support of empirical evidence.
In general BT seems to be the frontrunner in relation to the 4 important elements. However,
although a very small percentage of practitioners identify themselves as being primarily person
centered, a significant proportion of counselors, psychotherapists and social workers (typically
25-50%) identify PC as being an important part of their integrative approach (Kirschenbaum and
Jourdan, 2005). PC is indeed alive and well and could potentially offer a deeper understanding
of issues for clients that BT fails to provide. Most counselors operate from an eclectic model to
create a theory that fits both for themselves and their clients.
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