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Chapter 4: Person-Centred theory and ‘mental illness’
Paul Wilkins
Person-Centred Therapy has been criticised for its perceived lack of a theory of psychopathology and
therefore of differentiating the needs of clients experiencing mental ill-health. In this chapter, the validity
of this criticism is explored and rebutted with both reference to early theoretical statements and research
and to the views of current practitioner/researchers. Differences within the person-centred family of
therapies are indicated by briefly examining (for example) the situations in the UK and in continental
Europe.
Four major contemporary positions to mental ill-health within the person-centred tradition are explored.
These are those based on:
1.
2.
3.
4.
(Psychological) contact
Incongruence
Styles of processing
Issues of power
CASES FOR AND AGAINST: A MULTIPLICITY OF VIEWS
A therapy for the worried well?
One of the widespread beliefs therapists of other orientations have about Person-Centred Therapy is that
it is ‘psychotherapy lite’; that it may be perfect for those who are mildly and acutely disturbed but it lacks
the teeth necessary to get to grips with people experiencing real, chronic distress. On the other hand,
Person-Centred Therapy is also seen as useful for people who are so deeply disturbed or dysfunctional as
to be ‘unsuitable’ for psychotherapy (see Kovel 1976: 116). In other words, Person-Centred Therapy is not
going to do anything for ‘psychologically minded’ people with real problems. Also, practitioners of PersonCentred Therapy are seen as naively clinging to an optimistic (and outmoded) model of the person, a
commitment to a non-directive approach that prevents effective intervention and an antipathy to
assessment and diagnosis. Thus Person-Centred Therapy is criticised as lacking a theory of personality and,
in particular, of child development. This leads to an inadequate view of how (for example) neuroses and
psychoses may arise and thus how they may be addressed. These factors are seen to preclude any notion
of ‘psychopathology’. This is why Wheeler (in Wheeler and McLeod, 1995: 286) has two ‘serious
reservations’ about Person-Centred Therapy. Firstly, she is concerned that there is an assumption of
human goodness which does not hold water. Her second reservation is that there ‘is a lack of theory of
human growth and development to underpin the practice, and [a] subsequent disregard for assessment’.
The first of these doubts is easily dealt with. Person-centred theory makes no claim as to the inherent
‘goodness’ of people (see Wilkins, 2003: 60-3). The belief that it does seems to stem from a
misunderstanding of the concepts of the actualising tendency and what it means to be ‘fully functioning’.
These terms imply direction, not an end point and the actualising tendency is a biological force, common
to all living things. In incorporating these concepts into theory, no moral judgement is made or implied.
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Wheeler's second point presupposes that emotional distress and psychopathology can only be understood
in the context of a theory of child development. This is a belief, not a proven fact. An alternative belief,
perhaps more in keeping with a person-centred philosophy, is that mental distress is rooted in inequality
and ‘based on internalised oppression’ (see Proctor, 2002: 84). This leads to a need to consider the power
relationships and social position of the individual experiencing distress. However, Wheeler's assertion that
there is no person-centred theory of child development is an error. Rogers (1959: 222) postulated that:
‘the individual, during the period of infancy, has at least these attributes:
1. He perceives his experience as reality. His experience is his reality.
a. As a consequence he has greater potential awareness of what reality is for him than
does anyone else, since no one else can completely assume his internal frame of
reference.
2. He has an inherent tendency toward actualizing his organism.
3. He interacts with his reality in terms of his basic actualizing tendency. Thus his behavior is the
goal-directed attempt of the organism to satisfy the experienced needs for actualization in the
reality as perceived.
4. In this interaction he behaves as an organized whole, as a gestalt.
5. He engages in an organismic valuing process, valuing experience with reference to the
actualizing tendency as a criterion. Experiences which are perceived as maintaining or
enhancing the organism are valued positively. Those which are perceived as negating such
maintenance or enhancement are valued negatively.
6. He behaves with adience toward positively valued experiences and with avoidance toward
those negatively valued.’
In the same chapter, Rogers (pp. 224-6) explains the development of conditions of worth and (pp. 226-30)
the development of incongruence and its consequences. Indeed, Rogers (1959) includes comprehensive
theoretical statements about the human organism. He traces both ‘healthy’ development and
‘dysfunctional’ development and shows how there may be movement from ill-health to health. In this way,
Rogers' chapter can be seen as the bedrock on which person-centred theories of psychopathology may be
built.
Other person-centred theorists have modelled child development. Biermann-Ratjen (1996: 13), drawing on
Rogers' necessary and sufficient conditions, offers necessary conditions for self-development in early
childhood. These are:
1. That the baby is in contact with a significant other.
2. That the baby is preoccupied with evaluating experience which might possibly arouse anxiety.
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3. That the significant other person is congruent in the relationship to the baby, does not experience
anything inconsistent with her self concept while in contact with the baby when it is preoccupied
with evaluating [its] experience.
4. That the significant other is experiencing unconditional positive regard toward the baby's processes
of evaluating his experience.
5. That the significant other is experiencing an empathic understanding of the baby's experiencing
within his internal frame of reference.
6. That the baby gradually perceives both the unconditional positive regard of the significant other
person for him and the empathic understanding so that in the baby's awareness there is gradually
a belief or prognosis that the unconditionally positively regarding and empathically understanding
object would when reacting to other experiences of the baby also exhibit positive regard and
empathic understanding.
Biermann-Ratjen (p. 14) goes on to state ‘positive regard is the precondition for self development’. Rogers
(1959: 223) wrote that the need for positive regard is ‘universal in human beings, and in the individual, is
pervasive and persistent’. In person-centred theory, it is the pursuit of positive regard at the expense of
the organismic valuing process that underlies mental ill-health. Put another way, if there is sufficient
disharmony between the organism and the self (-concept), the resulting incongruence is likely to manifest
as one or more of the complexes of thinking, behaviour and processing which in other models may be
called neuroses and psychoses, mental illness or disease. Holdstock and Rogers (1977: 136) describe the
acquisition of psychological disturbance thus:
‘the continuing estrangement between self-concept and experience leads to increasingly rigid perceptions
and behavior. If experiences are extremely incongruent with the self-concept, the defence system will be
inadequate to prevent the experiences from overwhelming the self-concept. When this happens the selfconcept will break down, resulting in disorganization of behavior. This is conventionally classed as psychosis
when the disorganization is considerable.’
From the early days of Person-Centred Therapy, there have been theoretical explanations of the
acquisition and development of psychopathological ways of being and these have continued to be refined
and expanded (see, for example, Cooper, 2000: 87.-94). As well as the theoretical structures mentioned
above (and those below), in the simplest terms ‘disorder’ can be understood with reference to the
necessary and sufficient conditions. Thus difficulties with ‘communication’ (including autism, and some
other ‘special needs’) relate to ‘contact’ and ‘perception’ (conditions 1 and 6) while emotional distress and
thought disorder are to do with incongruence (condition 2). Of course, there is often overlap between the
two areas but the theories and practices of Person-Centred Therapy have evolved to take account of each.
In fact, work with ‘disturbed’ populations has been a feature of person-centred practice from at least the
1950s. It may be that practitioners of other orientations disagree with these theories and practices but
that is a very different position from being critical of their supposed absence.
AN HISTORICAL PERSPECTIVE
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Perhaps the best known and best documented early instance of person-centred practice with people
considered to be ‘mentally ill’ is the so-called ‘Wisconsin Project’. Barrett-Lennard (1998: 68-9, 267-70)
writes of this ‘massive study of psychotherapy with hospitalized schizophrenic patients’ which lasted for
much of the time Rogers worked at the University of Wisconsin (1957-1963) and led ultimately to the
publication of a massive report (see Rogers et a1., 1967). Besides Rogers, the project team comprised
Eugene Gendlin, Donald Kiesler and Charles Truax, with contributions from many others. Although it was a
difficult time for those concerned, riven with personal differences, leading to partings of the ways of
colleagues and erstwhile friends and added little to knowledge of Person-Centred Therapy, BarrettLennard (1998: 68) records that:
The work is more of a milestone in respect to the conduct and reporting of research in its complex sphere,
and in the development of strategies and instrumentation, than in terms of clear-cut findings from fully
tested hypotheses.
Also, although Shlien (2003:125) argues that the project as a whole ‘became a failure’ because the staff
team was ‘not prepared to provide Client-Centered Therapy that was adequate to test the hypotheses’ and
the research methods employed are now seen as flawed (see, for example, Prouty, 2001: 583-4), it did
offer evidence that high levels of congruence and empathy correlated with client improvement. Significant
publications other than that of Rogers et al. (1967) resulted from this study. Chief among these are Shlien's
1961 paper ‘A client-centered approach to schizophrenia: first approximation’ on his work with a deeply
disturbed client (see Shlien, 2003: 30-59), Gendlin (1963) and Rogers (1961 a) both of which ‘include direct
and sensitive portrayals of the human condition of the schizophrenic person’ (Barrett-Lennard, 1998: 68).
Also important in terms of the historical perspective on psychopathology in Person-Centred Therapy is the
symposium on psychodiagnosis published in Person-Centered Review printed in 1989 and reprinted in Cain
(2002). This is dealt with more thoroughly in the chapter on assessment (Wilkins, Chapter 9, this volume).
From the 1960s until the 1990s, as in so many other areas, research into Person-Centred Therapy with
schizophrenics and reports of case studies are largely absent from the (English language) literature.
Following a conference for client-centred and experiential psychotherapies in Leuven, Belgium, the
published proceedings contain two significant papers about working with schizophrenic people; Prouty
(1990) and Teusch (1990). This trend continued in the following international conferences on clientcentered and experiential counselling and psychotherapy. For example, Berghofer (1996) reports on her
work with long-term patients and (p. 492) concludes that ‘[t]he most important element in psychotherapy
with schizophrenic patients is the active establishment and maintenance of a reliable interpersonal
relationship’. Milsch (2000) too stresses the importance of the relationship in working with this client
group while Warner (2002a) emphasises not only the quality of the relationship but also the importance of
allowing this client group (and others experiencing ‘thought disorders’) to express themselves in their own
voices. She (p. 471) writes:
I suspect that the common psychiatric practice of ignoring or actively discouraging expressions that sound
psychotic may actually stop clients from processing experiences in ways that could allow them to gain a
more integrated sense of their own reactions and preferences.
Until the last decade of the 20th century, there does not seem to be much written about Person-Centred
Therapy with specific ‘disorders’ other than schizophrenia. The research effort in the 1960s and 1970s was
largely directed towards establishing the efficacy of the therapist conditions of congruence, empathy and
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unconditional regard. Although this research yielded some interesting results, as a way of testing Rogers'
hypothesis as to the necessity and sufficiency of the six conditions, because the therapist conditions were
usually separated from the other three and often attempts were made to consider them separately, it is
flawed. Another main area for research throughout this time and henceforward was into the comparative
effectiveness of Person-Centred Therapy with respect to other approaches. This too is suspect because, as
Elliott (2001: 67-5) confirms in his meta-analysis, ‘researcher allegiance’ (i.e. the approach to therapy to
which the researcher is predisposed) tends to influence findings. It is also true that, in terms of classic
Client-Centred Therapy, because there is only one ‘treatment’ regardless of the client's difficulty (see
Wilkins and Gill, 2003:177), there was little impetus to research the hows and whys of Person-Centred
Therapy with different issues and different client groups. However, Lambers (1994:106-20) did make an
important, accessible statement about ‘person-centred psychopathology’ setting out in straightforward
terms how the major psychiatric categories of:
 neurotic disorders
 borderline personality disorders
 psychotic disorders
 personality disorders
may be understood in a person-centred way. She (p.109) makes the ‘key point’ that although personcentred theoreticians and practitioners are resistant to diagnostic labels, ‘it is possible to understand, for
example, neurosis in terms of person-centred theory. Such an analysis may help the counsellor to
understand her own responses to the neurotic client’
Lambers (1994:106-7) understands neuroses in terms psychosomatic symptoms, anxiety and incongruent
communication. She (p.107) advances the idea that neurosis develops from strong conditions of worth, the
punishment for not conforming to which ‘took the form of withdrawal of affection and acceptance’
[original italics]. There is a resulting externalisation of the locus of evaluation, a negative self-concept,
feelings may be denied or distorted; in every way, neurosis equates with incongruence. Lambers (p. 110)
describes borderline personality disorder as characterised by a wide variety of symptoms and states that
the life of a person experiencing it ‘may appear chaotic’. She (pp. 110-11) sees the development of
borderline personality disorder as possibly developing from an inconsistency in conditions of worth and
experiences leading to an inability to develop a self-concept informed by experience. She (p.111) writes
that the self-concept of a person experiencing borderline personality disorder ‘lacks boundaries,
consistency, continuity and protection; it is constantly under threat as it has no effective means of
evaluating and integrating new experiences’. Borderline personality disorder is further characterised by
episodes of adequate functioning interspersed with times of chaos and disturbance. Lambers (p. 111) takes
the view that the defensive responses manifesting as disturbed behaviour ‘only occur in situations where
the self is threatened by new experiences’. Of psychosis, she (p. 113) reminds her readers that this is not a
diagnostic category but a description of a mental state characterised by withdrawal from normal contact
both with reality and with other people. She (pp. 113-14) goes on to reiterate Rogers' view that psychosis
is ‘a state of disintegration, involving the breakdown of the neurotic defences of denial and distortion and
the development of extreme forms of defence such as paranoid and catatonic behaviour’. The need for
such an extreme reaction Lambers (p. 114) understands in terms of an enormous threat to the self.
Personality disorder she (p. 116-17) describes in terms of ‘subjective distress or significant impairment of
the person's ability to function as a social being’ and as characterised by a sense that the causes of
misfortune and threat are located in others and outside the control of the sufferer. Lambers (p. 117) writes
that personality disorder arises from early significant relationships ‘characterised by neglect or persistent
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abuse of power’ in which ‘conditions of worth have been linked with satisfying the needs of those with the
power’. Because of the unpredictable nature of such relationships, people with personality disorders have
learned to live only in the moment and have not been able to learn from experience. This results in a
profound negation of self and a deep-seated sense of worthlessness. Lambers (p.118) states that ‘to bring
this core sense of worthlessness into awareness would be very dangerous’.
COMING UP TO DATE
In the later years of the 20th century and into the 21st century, this situation changed radically. This change
may be partly because of the need to demonstrate the effectiveness and applicability of the personcentred family of therapies to finders (healthcare providers, medical insurers and the like) but it also
reflects a zeitgeist. Whatever the reason, the person-centred community has turned its attention once
more to ‘psychopathology’.
This is evident, for example, from the review of research in the German language region produced by
Eckert et al., (2003) where (p. 5) they indicate that the focus of research has become ‘increasingly disorderspecific’ listing studies addressing:
 agoraphobia
 panic disorder
 borderline personality disorder
 depression
 psychosomatic disorders
More recently, there has also been a debate 'person-centred versus problem-centred' (see Takens and
Lietaer, 2004: 79-80). At one extreme, Sachse (2004: 24) argues:
[Client-Centered Therapy] urgently needs disorder-specific concepts ... Therapists must act in a more
disorder-specific fashion. To do this, they must first identify the disorder-they must make a diagnosis. To
do this they must have disorder-specific knowledge.
Sachse sees diagnosis as leading to a conclusion as to which therapeutic approaches a client will respond.
Mearns (2004: 89-90) casts doubt on the validity of a ‘problem-centred’ approach to mental illness
pointing out that there has been little serious, mainstream questioning of the appropriateness of the
medical model as a way of understanding mental health and demonstrating that individuals respond
differently to the same or similar stimuli. Because individuals who share a diagnosis (the example Meams
uses is alcoholism) almost certainly will not share (p. 90) ‘the constellation of [their] symbolizing of their
past, their present processing and their future vision for their self’ so disorder-specific treatment is a
nonsense. Schmid (2004: 46) takes a similar view stating:
Different ways of relating by the client in-form [sic] the therapist to relate and answer differently. This is
crucial, because the relationship is unique. Each client deserves to get the answer and relationship they
need and…not some preset ‘type of intervention’
For Mearns (2004: 94), the effective way of being with someone experiencing emotional distress or mental
ill-health is to work at relational depth; that is to engage with the client in a fully empathic, accepting and
congruent way (see also Mearns,1996). In his final paragraph Mearns (2004: 99) points out that clients'
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difficult processes (see below) are not problems in themselves but ‘both barriers and gateways’ to
engaging at relational depth. In conclusion, Mearns writes: ‘We do not need to be more than personcentered therapists; we just need to be good person-centred therapists.'
As the title of his 2004 paper suggests, Sachse is probably seen by himself (and certainly others) to have
deviated from the basic tenets of Client-Centred Therapy. Mearns on the other hand remains close to
classic Client-Centred Therapy although he places more emphasis on the centrality of the relationship.
Throughout their paper, Takens and Lietaer (2004)clear that others are positioned differently within this
spectrum. They (p. 85) emphasise that between the extremes there are those who experience the two
models as in tension rather than in conflict. This is their position and it is a tension they believe to be
fruitful.
MODELS OF PSYCHOPATHOLOGY IN PERSON-CENTRED THEORY AND PRACTICE
Treatment of people who are disturbed, suffering mental and/or emotional ill-health or what you will has,
in the West, been dominated by practitioners who adhere to a medical model whether they are medically
trained or not. So, an epistemology developed for the diagnosis and treatment of physical ailments has
been applied wholesale to maladies of mind and spirit without rigorous empirical testing. Barbara Douglas,
counselling psychologist and historian of the treatment of people experiencing mental ill-health (personal
communication, 2004) points out that early success in treating ‘general paralysis of the insane’ (late stage
syphilis) with a drug and some subsequent success in the drug treatment of neurological disorders
reinforced the notion of the applicability of a ‘(symptoms)-diagnosis-treatment-cure-(lack of symptoms)’
model to people whose disorder of thought and feeling is of other origins. This has not been established in
the same way. A second influence on psychotherapy has been psychoanalysis (which, to at least some
extent, can in itself be considered an offshoot of medicine). It is from this source that some of the labelling
language arises- ‘borderline personality’, ‘narcissism’, etc. Historically, both these ways of thinking about
people have been opposed by person-centred practitioners (although latterly there has been some move
towards a common language especially by those who practice in medical settings). There are personcentred alternatives, person-centred theories and practices amounting to ways of working with the
mentally and emotionally disturbed and distressed; some of them are described below.
PSYCHOLOGICAL CONTACT AND PSYCHOPATHOLOGY
One of the most important contributions to person-centred understanding and practice in the last years of
the 20th century was made as a result of Garry Prouty questioning what happens if the first of Rogers'
necessary and sufficient conditions for constructive, therapeutic change (that there be contact between
client and therapist) is not met. For me, the importance of this lies not only in the subsequent
development of theory and action (Pre-Therapy: see Prouty 2002a, b and c) but in the very raising of the
difficulty. As Sanders and Wyatt (2002: viii) indicate, over the years little attention has been paid to
‘contact/psychological contact’ and there is not really a definition of this concept - Rogers (1959: 207) is
vague suggesting that two people are in contact ‘when each makes a perceived or subceived difference in
the experiential field of the other’ and this looseness leads to a lack of agreement persisting to this day.
Wyatt and Sanders (2002) offer the first comprehensive exploration of contact (with perception condition
6)
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Prouty (2002b: 55) defines pre-therapy as ‘a theory of psychological contact ... rooted in Rogers'
conception of psychological contact as the first condition of a therapeutic relationship. This theory was
developed in the context of treating mentally retarded or psychotic populations' (Krietemeyer and Prouty,
2003: 152) because, in Prouty’s experience, such people are 'contact-impaired' and have difficulty forming
interpersonal connections. Prouty (2002b: 56-60) describes contact in terms of three levels: contact
reflections, contact functions and contact behaviours. These are summarised in Tudor and Merry (2002:
31-2). The theory led to a set of practices by which psychological contact could be established (see, for
example, the case studies presented by Van Werde (1994:125-8) and Krietemeyer and Prouty (2003: 15460)) and for which Prouty (2001; 595-6) summarises research evidence noting that (p. 596) ‘[p]ilot studies
with clients with severely limited mental abilities provide suggestive evidence for further empirical
exploration’.
Warner (2002b: 89-91) also pays attention to the role of contact in 'difficult process' -(see below for an
explanation of Warner's models of processing). She points out that (p. 89) ‘being blocked from
psychological contact is almost always experienced as an affliction’ and briefly describes the contactimpairment likely or possible in people experiencing fragile, dissociated and psychotic process.
THEORIES OF INCONGRUENCE
In person-centred theory, it is explicit that extreme incongruence is what leads to mental ill-health or, if
you prefer, it is the conditions of worth leading to incongruence that are the roots of psychological
disturbance. As stated in the fourteenth of Rogers (1951: 483-522) nineteen propositions:
Psychological maladjustment exists when the organism denies to awareness significant sensory and
visceral experiences, which consequently are not symbolized and organized into the gestalt of the selfstructure. When this situation exists, there is a basic or potential psychological tension.
This Merry (2002: 36) helpfully rephrases as ‘When we experience something that doesn't fit in with our
picture of ourselves and we cannot fit it in with that picture, we feel tense, anxious, frightened or
confused.’ When a person has a poor self-concept which is out of touch with the organism, she or he is
disturbed. In extreme cases, this manifests as ‘madness’. Since incongruence is central to
mental/emotional distress, it follows that person-centred practitioner/theoreticians base models of
psychopathology around it. Thus, Van Kalmthout (2002,134,135-6) asserts that avoiding experiencing
‘what there really is’ and the resulting lack of contact between inner and outer reality ‘can lead to
problems and even psychopathology’. Speierer (1996: 300) goes so far as to state 'client-centered therapy
is ... the treatment of incongruence' and (1990, 1996) proposes a ‘differential incongruence model’ which
(1996: 299) offers ‘a specific illness concept for client-centered psychotherapy’. Speierer's contention is
that incongruence is the root of emotional distress and that it has three main causes. These are (1996:
299):
 ‘well-known client-centered social communicative factors’ by which Speierer means the acquisition of
conditions of worth and a ‘form of incompatibility between societal and organismic values’
 ‘a non-socially caused bio-neuropsychological inability to reach congruence’
 ‘social and non-social life-changing events’
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Speierer's model goes far beyond the concepts of classic Client-Centred Therapy not least because he is
suggesting that different ‘disorders’ are the result of differences in incongruence and then he draws the
conclusion that (1996: 307) ‘different therapy options can be offered according to the individual's needs
and his disorder’.
Biermann-Ratjen (1998) also writes about incongruence and psychopathology. She devotes sections to
‘post-traumatic stress disorder’, ‘psychogenic illnesses’ and ‘neurosis’ as manifestations of incongruence.
For example, she (p.126-7) writes:
‘Any symptom of psychogenic illness is the expression of experiencing incongruence:
1. The person may be unable to symbolize completely and communicate verbally certain
experiences.
2. The person may be unable to understand and/or accept certain experiences as selfexperiences.
3. The person may experience certain ways of defending against experience (stress reactions,
acute incongruence) or different forms of stagnation in self-development (chronic
incongruence).
4. In any case experiencing incongruence will include experiencing physical tension’
For Biermann-Ratjen, it is at what stage self development is interrupted that determines the nature of
distress.
STYLES OF PROCESSING
Rogers (1961b: 27) refers to life as ‘a flowing, changing process in which nothing is fixed’. He also (p.126,
p.171) refers to an acceptance of the fluid nature of existence as an outcome of therapy and (p.186)
characterises the ‘good life’ as ‘a process, not a state of being’. He also (pp. 132-55) described the seven
stages of process in therapy by which an individual changes from fixedness to a fluid way of being. From
this, it is clear that people are defined as ‘in process’ rather than as of a particular ‘personality type’. A
person’s process is their way of experiencing and encountering the world, a way of making sense of all the
stimuli and information to which they are exposed. Process is cognitive, behavioural, emotional and
(arguably at least) spiritual. Worsley (2002: 21) points out that process is both in and out of awareness and
may be either reflexive or spontaneous. Also, a person’s process may flow in the easy way Rogers
described as desirable or it may be ‘difficult’ (and, of course all stages between). The notion of difficult
process forms the basis of theory and practice of Warner (1998, 2000, 2002a. 2002b) Warner describes
three kinds of difficult process (summarised briefly in Warner, 2001:182-3). These are:
Fragile process: ‘Clients who have a fragile style of processing tend to experience core issues at very low or
very high levels of intensity. They tend to have difficulty starting and stopping experiences that are
personally significant or emotionally connected. In addition, they are likely to have difficulty taking the
point of view of another person while remaining in contact with such experiences’ (Warner, 2000:150).
Dissociated process: ‘Clients who experience "dissociated process" go through periods of time when they
quite convincingly experience themselves as having selves that are not integrated with each other.
Sometimes, they experience a disunity of self that feels "crazy" to themselves and to others. At other times
they may have periods of forgetfulness for the minutes or hours when alternate personality parts have
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been dominant. They may go for years without being aware of such parts by keeping very busy and leading
quite restricted lives, only to have past experiences return in times of crisis’ (Warner, 2001: 183).
Psychotic process: ‘When clients have a psychotic style of processing, they have difficulty forming
narratives about their experience that make sense within the culture, or which offer a predictive value in
relation to their environment. Clients experiencing psychotic process ... (have) impaired contact with ‘self’,
‘world’ and ‘other’. Such clients often experience voices, hallucinations or delusions that are neither
culturally accepted nor are easy to process’ (Warner, 2001:183).
In her various papers, Warner describes the possible origins of these styles of processing and effective
ways of working with each group of clients in a person-centred way.
Mearns (2004: 99) indicates that he, with Mick Cooper, is investigating a fourth style of processing which
they are currently calling disconnected process. In this style of processing, the actualising tendency and an
inferred balancing process of social mediation (see Mearns and Thorne, 2000:178-86) ‘are separating and
creating disjunctions between the self and the phenomenological context’.
Although these styles of processing may be identified with traditional psychiatric/ psychoanalytic
categories, they are conceived of in a very different way and the methods of working with people
experiencing difficult process are firmly rooted in person-centred practice.
POWER AND MENTAL AND EMOTIONAL DISTRESS
Another view of the aetiology of mental and emotional distress which is compatible with person-centred
theory and practice but which moves away from the notion that such difficulties are intrinsic, intrapersonal and a response to relationships with significant others is social and/or environmental. Proctor
(2402: 3) is clear that ‘there is much evidence to associate the likelihood of suffering from psychological
distress with the individual's position in society with respect to structural power’. She (pp. 3-4) shows how
women are more likely than men to be diagnosed with a range of disorders and that working class people
as a whole are over-represented in the mental illness statistics.
It is argued that psychiatric systems are inherently systems of control and power. It follows that if distress
flows from an experience of inequality and an encounter with psychiatric services is disempowering, then
psychiatry may be making people worse rather than better. In a much more sophisticated way, this is the
case made by the anti-psychiatry movement (proponents of which include Szasz and Laing) and, currently,
by those involved in critical psychology (see, for example, Newnes et al., 1999 and 2001). As articulated by
Holmes and Dunn (1999: 2), critical psychology ‘lays down a challenge to the idea that the psychiatric
system is largely benign’. In the same book, Newnes and Holmes (1999: 281-2) offer a view as to the role
of ‘talking therapies’ in the future of mental health services. Although they (p. 28I) are wary of ‘the dangers
and limits of talking therapies’, they see value in ‘collaborative conversation’ in which therapist and client
meet with the intention ‘to understand each other and work together on the [client's] goals’. They (p. 282)
also emphasise the importance of ‘empathy through personal disclosure’ as a ‘powerful way of relating to
and helping people’. Proctor (2002: 90) refers to the demystification of therapy as a way of addressing the
imbalance of power in the therapy relationship and states ‘the demystification of my therapist as a person
was a strong factor in my not feeling disempowered in the relationship’. In Person-Centred Therapy, the
relationship is seen to be at the centre and, in respect of it, there is a case to be made for ‘willingness to be
known’ on the part of the therapist so perhaps it can go some way to meeting the needs seen by Newnes
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Joseph, S. Worsley, R. Eds (2005) Person-Centred Psychopathology: A Positive Psychology of Mental Health. PCCS Books
and Holmes. Certainly, Pete Sanders (speaking at the 2nd Conference held by the British Association for the
Person-Centred Approach) and Gillian Proctor (2002: 103) both emphasise the potential for PersonCentred Therapy to offer a radical alternative to orthodox psychiatry (and medicalised psychotherapy) and
(Proctor, 2002:103) ‘to emphasise the autonomy and trustworthiness of the client’. However, Proctor
(2002:137) warns that although Person-Centred Therapy, ‘addresses all aspects of power in the therapy
relationship’ there is a danger that ‘the focus on the therapist as a person’ may obscure ‘the power
inherent in the role of therapist’. She also sees that within Person-Centred Therapy, ‘there is the potential
for therapists to miss levels of oppression resulting from structural positions unless the socially positioned
person is acknowledged’. This is something to be addressed if the criticisms of the critical psychology
movement are to be rebutted. A person-centred model to address power issues would involve working at
‘relational depth’ but it would also take account of inequalities of structural power both within and without
the therapy relationship.
The position of Person-Centred Therapy with respect to the contemporary psychiatric system is explored
and explicated by Sanders and Tudor (2001). They (p.148) declare ‘we are proponents of the PersonCentred Approach precisely because it offers a radical view of psychology and psychotherapy and a critical
contribution to contemporary concerns about mental health’ They are equally clear that they are not
uncritical of Person-Centred Therapy. For example, throughout their chapter, they argue that to consider
individuals separately from the social and political milieus m which they live is a shortcoming of
psychotherapy and one by which Person-Centred Therapy is not untainted. Using Rogers' notion of process
as an inspiration, Sanders and Tudor (pp. 156-7) characterise:
 a [r]evolutionary effect on psychiatry and mental health services, based on movement towards:
 A non-defensive openness in all interpersonal relationships – throughout the psychiatric system,
regardless of status.
 A holistic approach and attitude to the individual - for example, complementary health
practitioners working in psychiatric services.
 Human-sized, rather than institutional-sized, groupings - reflected in an emphasis on small units at
all levels of the psychiatric system (i.e. primary, secondary and tertiary).
 Attention to the quality of personal living - both in the community and in the asylum (crisis house,
hospital, etc.).
 A more genuine and inclusive caring concern for those who need help - which would require a
radical shift of thinking and practice on community care ... and an openness to creative,
therapeutic alternatives to institutional care
Behind all the views presented in this section is an assumption that ‘madness’ is socially defined and that
social and political circumstances at the very least contribute to mental ill-health and are possibly causal.
There is also a belief that the imbalance and abuse of power relate to mental ill-health and that it is only if
power in all its aspects is openly addressed can therapy be successful. In this model of mental disturbance,
although there is a challenge to person-centred theory and practice, it is one that it may meet more easily
than many other approaches.
CONCLUSION
It is clear that, although the term may have been resisted, from its earliest days Person-Centred Therapy
has been concerned with the issue of ‘psychopathology’. Rogers and his collaborators went to great pains
to present theories of development and explanations for maladjustment which they then attempted to
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Joseph, S. Worsley, R. Eds (2005) Person-Centred Psychopathology: A Positive Psychology of Mental Health. PCCS Books
test in a variety of therapeutic situations. More recently, early client-centred theoretical statements have
been reinterpreted to offer (for example) theories of child development and support for different
conceptions of working with people experiencing more extreme forms of emotional and mental distress.
For the most part, these different conceptions of ‘psychopathology’ draw on the original six necessary and
sufficient conditions for constructive personality change, the different emphases resulting from the
originators' experience and allegiance (for example, whether closer to client-centred or experiential
traditions). Presumably in the interests of dialogue and mutual understanding, these models also tend to
draw to some extent on the language of psychiatry and psychoanalysis (although most usually to point out
person-centred conceptions of phenomena recognised in these ways of thinking). An exception is the idea
that the Person-Centred Approach could (and should?) offer a radical alternative to existing philosophies
and practices in the mental health system. Adherents of this view are inclined to the belief that by being
true to its roots and by drawing on its strengths with respect to the exercise of power and as a sociopolitical model as much as an intra- and interpersonal one, the Person-Centred Approach can become a
natural ally to the critical psychology movement in developing real and effective alternatives to current
mental health practices.
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