Can a humanistic model of counselling be integrated with a cognitive one?

In this essay I am going to compare the Person-Centred Therapy founded by Carl Rogers and the Cognitive Therapy Model of Aaron Becks. I shall compare the two approaches, outlining the theory to explain their similarities as well as their differences. I shall compare the two approaches to show whether a humanistic and cognitive approach can be integrated successfully into a therapy session. In order to compare the two approaches it is necessary to summarise the main features of the two. Cognitive Therapy in brief can be described as: 1. Formulating a plan for treatment. 2. Focussing on the current, presenting problems as defined by the client. 3. Goal setting. 4. Time-limited. 5. Agreement to set and complete homework. 6. Connecting the way a client thinks about situations and how they feel and behave in order to change these thoughts. 7. Assisting the client in identifying and using coping skills for self-help in the future.
Cognitive Therapy (CT) is organised around a formulation devised by Becks in 1976 to assist patients who were suffering from depression. The aim of CT is to understand the person's environment, values, beliefs and the way the person assesses events in their life. The CT model evaluates how people believe that a situation affects their feelings, behaviour and their view of 'self' and 'others'. A CT Therapist believes these views will be distorted and this distortion causes the clients problems. The therapist refers to these beliefs as negative automatic thoughts (NATs). The CT therapist will therefore work with a client's NATs to help the client to see these views as inaccurate. The CT therapist will do this by challenging the clients perceptions of their views (commonly called core beliefs (or schemas)) of themselves and the world around them in order for the client to develop a more balanced and accurate view. A CT therapist will ask for clarification of their understanding of presenting situations and seek to find a link between the clients thoughts/feelings and their behaviour. They will also challenge the unhelpful rules that the client has put in place. Once these have been identified, the next stage of CT is to learn to 'distance' these behaviours (Becks 1976 pg 243). The therapist will set a client homework in which they will challenge their core beliefs and begin to distance themselves from their NATs. Distancing means that the client is able to identify and view their thoughts objectively. A client who can do this will be able to distinguish between what they think or believe and what they know to be a fact. The CT therapist will employ different tactics of the CT model in order to develop an 'over-all strategy for a given case' to treat the specific needs of the patient. Without such guidance, Becks suggested that 'the therapy may follow an erratic course based on trial and error' (Becks 1976, p258). A Person-Centred Therapeutic approach is best described in the words of Rogers (1957, pg 1-2) himself. Rogers said that 'for therapy to occur it is necessary that the following conditions existed; 1. That two persons are in psychological contact. 2. That the first person, whom we shall term the client is in a state of incongruence, being vulnerable or anxious. 3. That the second person, whom we shall term the therapist, is congruent in the relationship. 4. That the therapist is experiencing unconditional positive regard toward the client. 5. That the therapist is experiencing an empathic understanding of the client's internal frame of reference. 6. That the client perceives, at least to a minimal degree, conditions 3, 4 and 5, the unconditional positive regard of the therapist for him, and the empathic understanding of the therapist' .

These six conditions are more commonly reduced to the three core conditions of Empathy, Congruence and Unconditional Positive Regard (UPR). This does not mean that the others can be forgotten. Rogers inherently believed the three conditions other than empathy, congurence and UPR should be present as a matter of course when in a therapuetic session. All six conditions were not only necessary when working as a Person-Centred Therapy (PCT) therapist, but within any model of therapy. Roger's believed that all people are potentially good and trustworthy. He felt a client had the ability to know what they needed in order to 'heal' themselves. Rogers believed in the actualising tendency of a person; this is where the person's full potential within the world can be realised. PCT, as a humanistic model of counselling takes a phenomenological approach; this means that we live in our own world only fully understood by ourselves; it is the way in which we see our world, and respond to it in order to have our needs met. Rogers also believed in an existential view on living which puts the onus on the client to take ownership of their experiences. Rogers believed that being with a client and allowing the six core conditions to be explored, would allow the client to find their own conditions of worth and not look for these from others (called internal locus of evalutation). Roger's believed that PCT is an effective way of promoting personal change as it increases a person's self-esteem and allows a person to have a greater openness with themselves and others. A psychological diagnosis of a patient was not required in order to have success when counselling and therefore no treatment plan was required for the PCT client. Merry (2002) uses the following quote from Patterson (1995) in regard to describing Roger's 'goal' for Person Centred Therapy; 'the ultimate goal of counselling in terms of actualisation, also makes the point that this is a universal human goal, and so person-centred counselling, in not describing specific behavioural goals'. Roger's only treatment 'goal' is to establish the six conditions in order to build a relationship with the client in which they felt secure and able to promote inner change. Merry further states that the PCT approach rejected the normal standards of therapy in which a client is assessed, diagnosed and labelled. The process of labelling or seeking to diagnose is seen as damaging to the client and the therapist should obtain a deep understanding of the client’s own experiences and be part of their journey as a companion, rather than as a facilitator.

Both approaches focus on how beliefs influence the client, their behaviour and feelings. CT focusses on the 'here and now' in a similar way to the PCT model. A CT therapist doesn'tlook into the client's personal history or take into consideration a client's upbringing or life experiences when starting therapy. They would only know information the client told them during their sessions and this information would remain untouched by the CT therapist if it was not seen as important in enabling the client to reach their end goal. This reminds me of plasters – they assist with the healing process of minor wounds and injuries and in many cases, the short-term use of the plaster will help. In some cases though, the plaster may have been applied too late and won't assist with the healing process at all and only masks the infection manifesting beneath. In cases such as these, another therapy model may be more appropriate to use or integrated into the session. In PCT the therapist would not delve into the client's past unless the client went there. Both approaches are very similar in that they tend to ignore the past experiences of the client, believing that the past is past and therefore cannot be altered. CT and PCT believe that changing the clients 'now' will allow the client to see their future differently With this in mind the PCT approach can be seen as being woolly and lacking any direction or focus. CT can therfore be the flip-side of the coin and be seen as goal focussed, time-limited and based on methods derived from a theoritical base. Wills states 'Cognitive Therapy is potentially, the most self limiting therapy model: it is literally only as much use as its applications and its results.........the cognitive therapist should have no hesitation in abandoning current methods and taking up these alternatives no matter how close to or distant they may be from Cognitive Therapy models' (Wills, 2009 pg 24). By this he means that some critics of CT feel that if research begins to point to other therapies being more effective then this could lead to therapists moving away from the CT model. He may be also suggesting that one fixed approach of CT would not be the correct approach to be used when counselling.

In my opinion both therapies seem to steer away diversity and the differences associated with clients, claiming that focus is on the clients 'uniqueness', therefore they are able to be used with any client to a satisfactory end. Merry (2002) writes that it is important for a PCT therapist to understand the society's structure of the area in which we work, including knowing the cultural groups that clients come from. Further more Merry states that it is important for the therapist to understand the prejudice and discrimination faced by these potential clients and that a therapist should take time to understand and work with their own prejudices and stereotyping in order to assist with showing empathy, congruence and UPR to clients from any background. Patterson as quoted by Merry (2002), said, person-centred counselling 'is not culture-bound or culture-dependent'. It seems that Patterson believed that Roger's wanted his approach to be used for everyone, irrespective of their cultural background. The following statement has been taken from a handbook given to all Medway Primary Care Trust's staff. 'Diversity is about valuing difference. It is not about treating everyone in the same way as many of us have different needs, it is though, about treating everyone with equal respect'. (The Grass Roots 2006 pg26). It is important to understand diversity and how this may affect working practices and by having an awareness both models can be used affectively across all.

As a Samaritan I use the core conditions of empathy, congruence and unconditional positive regard with all callers to the service, regardless of their ethnic origin, social status; whether they are gay, lesbian or bisexual. Using these conditions with a caller is paramount in order for the Samaritan and the caller to build a relationship for the duration of the call. I am not concerned with their 'label' and want to understand their reason for calling and identify their thought processes in the 'here and now'. The tool of reflecting feelings is taught within the Samaritan training and is something that I use often in my calls. I had up till now thought that this tehcnique did not allow progression within a call as it lacked direction for the caller. I am aware that this is how many people perceive PCT. What was refreshing to me was to read that integrative approaches have seemed to have evolved into 'empathic reflection of feelings' and this is more in line with Roger's intention of showing the client that you have the intention of following their experience in an empathic way. Reflecting is therefore more about giving empathy than repeating back to the client/caller what has been said. It seems a simple connection to make but is one that I was beginning to struggle with, believing that the further into my counselling training I was heading, the less able I felt to work within the Samaritan ethos. I have now realised that it was my personal interpretations of these guidelines that had gone adrift and this essay has made me realise that I can work at the Samaritans using a person-centred approach in which the caller chooses the direction of the call. Recent changes to the Samaritans have also begun to allow some directional focus in that callers can be given details of organistations who may assist them with certain issues such as drug abuse, or alcohol dependency.

At first glance it could be suggested that integrating a PCT and CT approach would be difficult in so far as the PCT approach may last many months or even years, whereas CT is time-limited to usually between 6 to 10 sessions. It would therefore seem an impossibility to integrate approaches with such differing timeframes in the first instance. But when looking further into the two models, there are similarities; if working with a client who was self-aware to use PCT terminology and they felt able to work within the CT model I.e. willing to undertake homework or allow the PCT therapist to act as a facilitator in order to work through a specific problem, it could only be beneficial to them to have this model integrated into their counselling. A CT therapist should also be able to integrate PCT approaches into their working relationship by ensuring that the six core conditions of Rogers are in place when counselling a client. It could therefore be challenging to integrate a humanistic and cognitive model on the surface and for every client it would not be appropriate, but for some, the approach would work well in identifying and assisting with problems.

References:
Aaron T Becks (1976), Cognitive Therapy and the Emotional Disorders, Penguin books
Frank Wills (2009), Beck's Cognitive Therapy, Routledge Taylor & Francis Group
The Grass Roots, (c.2006), Diversity Workbook – Respect for People
Carl R Rogers (1957), The Necessary and Sufficient Conditions of Therapeutic Personality Change, Journal of Consulting Psychology, Vol 21 pg 95-103 LEB