Journal of Consulting and Clinical Psychology © 1992 by the American Psychological Association December 1992 Vol. 60, No. 6, 827-832 For personal use only--not for distribution. The Necessary and Sufficient Conditions of Therapeutic Personality Change Carl R. Rogers University of Chicago Received: June 6, 1956. For many years I have been engaged in psychotherapy with individuals in distress. In recent years I have found myself increasingly concerned with the process of abstracting from that experience the general principles which appear to be involved in it. I have endeavored to discover any orderliness, any unity which seems to inhere in the subtle, complex tissue of interpersonal relationship in which I have so constantly been immersed in therapeutic work. One of the current products of this concern is an attempt to state, in formal terms, a theory of psychotherapy, of personality, and of interpersonal relationships which will encompass and contain the phenomena of my experience. 1 What I wish to do in this paper is to take one very small segment of that theory, spell it out more completely, and explore its meaning and usefulness. The Problem The question to address myself is this: Is it possible to state, in terms which are clearly definable and measurable, the psychological conditions which are both necessary and sufficient to bring about constructive personality change? Do we, in other words, know with any precision those elements which are essential if psychotherapeutic change is to ensue? Before proceeding to the major task let me dispose very briefly of the second portion of the question. What is meant by such phrases as "psychotherapeutic change," "constructive personality change"? This problem also deserves deep and serious consideration, but for the moment let me suggest a commonsense type of meaning upon which we can perhaps agree for purposes of this paper. By these phrases is meant: change in the personality structure of the individual, at both surface and deeper levels, in a direction which clinicians would agree means greater integration, less internal conflict, more energy utilizable for effective living; change in behavior away from behaviors generally regarded as immature and toward behaviors regarded as mature. This brief description may suffice to indicate the kind of change for which we are considering the preconditions. It may also suggest the ways in which this criterion of change may be determined. 2 The Conditions As I have considered my own clinical experience and that of my colleagues, together with the pertinent research which is available, I have drawn out several conditions which seem to me to be necessary to initiate constructive personality change, and which, taken together, appear to be sufficient to inaugurate that process. As I have worked on this problem I have found myself surprised at the simplicity of what has emerged. The statement which follows is not offered with any assurance as to its correctness, but with the expectation that it will have the value of any theory, namely that it states or implies a series of hypotheses which are open to proof or disproof, thereby clarifying and extending our knowledge of the field. Since I am not, in this paper, trying to achieve suspense, I will state at once, in severely rigorous and summarized terms, the six conditions which I have come to feel are basic to the process of personality change. The meaning of a number of the terms is not immediately evident, but will be clarified in the explanatory sections which follow. It is hoped that this brief statement will have much more significance to the reader when he has completed the paper. Without further introduction let me state the basic theoretical position. For constructive personality change to occur, it is necessary that these conditions exist and continue over a period of time: • Two persons are in psychological contact. • The first, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious. • The second person, whom we shall term the therapist, is congruent or integrated in the relationship. • The therapist experiences unconditional positive regard for the client. • The therapist experiences an empathic understanding of the client's internal frame of reference and endeavors to communicate this experience to the client. • The communication to the client of the therapist's empathic understanding and unconditional positive regard is to a minimal degree achieved. No other conditions are necessary. If these six conditions exist, and continue over a period of time, this is sufficient. The process of constructive personality change will follow. A Relationship The first condition specifies that a minimal relationship, a psychological contact, must exist. I am hypothesizing that significant positive personality change does not occur except in a relationship. This is of course an hypothesis, and it may be disproved. Conditions 2 through 6 define the characteristics of the relationship which are regarded as essential by defining the necessary characteristics of each person in the relationship. All that is intended by this first condition is to specify that the two people are to some degree in contact, that each makes some perceived difference in the experiential field of the other. Probably it is sufficient if each makes some "subceived" difference, even though the individual may not be consciously aware of this impact. Thus it might be difficult to know whether a catatonic patient perceives a therapist's presence as making a difference to him–a difference of any kind–but it is almost certain that at some organic level he does sense this difference. Except in such a difficult borderline situation as that just mentioned, it would be relatively easy to define this condition in operational terms and thus determine, from a hard-boiled research point of view, whether the condition does, or does not, exist. The simplest method of determination involves simply the awareness of both client and therapist. If each is aware of being in personal or psychological contact with the other, then this condition is met. This first condition of therapeutic change is such a simple one that perhaps it should be labeled an assumption or a precondition in order to set it apart from those that follow. Without it, however, the remaining items would have no meaning, and that is the reason for including it. The State of the Client It was specified that it is necessary that the client be "in a state of incongruence, being vulnerable or anxious." What is the meaning of these terms? Incongruence is a basic construct in the theory we have been developing. It refers to a discrepancy between the actual experience of the organism and the self picture of the individual insofar as it represents that experience. Thus a student may experience, at a total or organismic level, a fear of the university and of examinations which are given on the third floor of a certain building, since these may demonstrate a fundamental inadequacy in him. Since such a fear of his inadequacy is decidedly at odds with his concept of himself, this experience is represented (distortedly) in his awareness as an unreasonable fear of climbing stairs in this building, or any building, and soon an unreasonable fear of crossing the open campus. Thus there is a fundamental discrepancy between the experienced meaning of the situation as it registers in his organism and the symbolic representation of that experience in awareness in such a way that it does not conflict with the picture he has of himself. In this case to admit a fear of inadequacy would contradict the picture he holds of himself; to admit incomprehensible fears does not contradict his self concept. Another instance would be the mother who develops vague illnesses whenever her only son makes plans to leave home. The actual desire is to hold on to her only source of satisfaction. To perceive this in awareness would be inconsistent with the picture she holds of herself as a good mother. Illness, however, is consistent with her self concept, and the experience is symbolized in this distorted fashion. Thus again there is a basic incongruence between the self as perceived (in this case as an ill mother needing attention) and the actual experience (in this case the desire to hold on to her son). When the individual has no awareness of such incongruence in himself, then he is merely vulnerable to the possibility of anxiety and disorganization. Some experience might occur so suddenly or so obviously that the incongruence could not be denied. Therefore, the person is vulnerable to such a possibility. If the individual dimly perceives such an incongruence in himself, then a tension state occurs which is known as anxiety. The incongruence need not be sharply perceived. It is enough that it is subceived–that is, discriminated as threatening to the self without any awareness of the content of that threat. Such anxiety is often seen in therapy as the individual approaches awareness of some element of his experience which is in sharp contradiction to his self concept. It is not easy to give precise operational definition to this second of the six conditions, yet to some degree this has been achieved. Several research workers have defined the self concept by means of a Q sort by the individual of a list of self-referent items. This gives us an operational picture of the self. The total experiencing of the individual is more difficult to capture. Chodorkoff (2) has defined it as a Q sort made by a clinician who sorts the same self-referent items independently, basing his sorting on the picture he has obtained of the individual from projective tests. His sort thus includes unconscious as well as conscious elements of the individual's experience, thus representing (in an admittedly imperfect way) the totality of the client's experience. The correlation between these two sortings gives a crude operational measure of incongruence between self and experience, low or negative correlation representing of course a high degree of incongruence. The Therapist's Genuineness in the Relationship The third condition is that the therapist should be, within the confines of this relationship, a congruent, genuine, integrated person. It means that within the relationship he is freely and deeply himself, with his actual experience accurately represented by his awareness of himself. It is the opposite of presenting a facade, either knowingly or unknowingly. It is not necessary (nor is it possible) that the therapist be a paragon who exhibits this degree of integration, of wholeness, in every aspect of his life. It is sufficient that he is accurately himself in this hour of this relationship, that in this basic sense he is what he actually is, in this moment of time. It should be clear that this includes being himself even in ways which are not regarded as ideal for psychotherapy. His experience may be "I am afraid of this client" or "My attention is so focused on my own problems that I can scarcely listen to him." If the therapist is not denying these feelings to awareness, but is able freely to be them (as well as being his other feelings), then the condition we have stated is met. It would take us too far afield to consider the puzzling matter as to the degree to which the therapist overtly communicates this reality in himself to the client. Certainly the aim is not for the therapist to express or talk out his own feelings, but primarily that he should not be deceiving the client as to himself. At times he may need to talk out some of his own feelings (either to the client, or to a colleague or supervisor) if they are standing in the way of the two following conditions. It is not too difficult to suggest an operational definition for this third condition. We resort again to Q technique. If the therapist sorts a series of items relevant to the relationship (using a list similar to the ones developed by Fiedler [3 , 4] and Bown [1] ), this will give his perception of his experience in the relationship. If several judges who have observed the interview or listened to a recording of it (or observed a sound movie of it) now sort the same items to represent their perception of the relationship, this second sorting should catch those elements of the therapist's behavior and inferred attitudes of which he is unaware, as well as those of which he is aware. Thus a high correlation between the therapist's sort and the observer's sort would represent in crude form an operational definition of the therapist's congruence or integration in the relationship; and a low correlation, the opposite. Unconditional Positive Regard To the extent that the therapist finds himself experiencing a warm acceptance of each aspect of the client's experience as being a part of that client, he is experiencing unconditional positive regard. This concept has been developed by Standal (8) . It means that there are no conditions of acceptance, no feeling of "I like you only if you are thus and so." It means a "prizing" of the person, as Dewey has used that term. It is at the opposite pole from a selective evaluating attitude–"You are bad in these ways, good in those." It involves as much feeling of acceptance for the client's expression of negative, "bad," painful, fearful, defensive, abnormal feelings as for his expression of "good," positive, mature, confident, social feelings, as much acceptance of ways in which he is inconsistent as of ways in which he is consistent. It means a caring for the client, but not in a possessive way or in such a way as simply to satisfy the therapist's own needs. It means a caring for the client as a separate person, with permission to have his own feelings, his own experiences. One client describes the therapist as "fostering my possession of my own experience . . . that [this] is my experience and that I am actually having it: thinking what I think, feeling what I feel, wanting what I want, fearing what I fear: no 'ifs,' 'buts,' or 'not reallys.'" This is the type of acceptance which is hypothesized as being necessary if personality change is to occur. Like the two previous conditions, this fourth condition is a matter of degree, 3 as immediately becomes apparent if we attempt to define it in terms of specific research operations. One such method of giving it definition would be to consider the Q sort for the relationship as described under Condition 3. To the extent that items expressive of unconditional positive regard are sorted as characteristic of the relationship by both the therapist and the observers, unconditional positive regard might be said to exist. Such items might include statements of this order: "I feel no revulsion at anything the client says": "I feel neither approval nor disapproval of the client and his statements–simply acceptance"; "I feel warmly toward the client–toward his weaknesses and problems as well as his potentialities"; "I am not inclined to pass judgment on what the client tells me"; "I like the client." To the extent that both therapist and observers perceive these items as characteristic, or their opposites as uncharacteristic, Condition 4 might be said to be met. Empathy The fifth condition is that the therapist is experiencing an accurate, empathic understanding of the client's awareness of his own experience. To sense the client's private world as if it were your own, but without ever losing the "as if" quality–this is empathy, and this seems essential to therapy. To sense the client's anger, fear, or confusion as if it were your own, yet without your own anger, fear, or confusion getting bound up in it, is the condition we are endeavoring to describe. When the client's world is this clear to the therapist, and he moves about in it freely, then he can both communicate his understanding of what is clearly known to the client and can also voice meanings in the client's experience of which the client is scarcely aware. As one client described this second aspect: "Every now and again, with me in a tangle of thought and feeling, screwed up in a web of mutually divergent lines of movement, with impulses from different parts of me, and me feeling the feeling of its being all too much and suchlike–then whomp, just like a sunbeam thrusting its way through cloudbanks and tangles of foliage to spread a circle of light on a tangle of forest paths, came some comment from you. [It was] clarity, even disentanglement, an additional twist to the picture, a putting in place. Then the consequence–the sense of moving on, the relaxation. These were sunbeams." That such penetrating empathy is important for therapy is indicated by Fiedler's research (3) in which items such as the following placed high in the description of relationships created by experienced therapists: The therapist is well able to understand the patient's feelings. The therapist is never in any doubt about what the patient means. The therapist's remarks fit in just right with the patient's mood and content. The therapist's tone of voice conveys the complete ability to share the patient's feelings. An operational definition of the therapist's empathy could be provided in different ways. Use might be made of the Q sort described under Condition 3. To the degree that items descriptive of accurate empathy were sorted as characteristic by both the therapist and the observers, this condition would be regarded as existing. Another way of defining this condition would be for both client and therapist to sort a list of items descriptive of client feelings. Each would sort independently, the task being to represent the feelings which the client had experienced during a just completed interview. If the correlation between client and therapist sortings were high, accurate empathy would be said to exist, a low correlation indicating the opposite conclusion. Still another way of measuring empathy would be for trained judges to rate the depth and accuracy of the therapist's empathy on the basis of listening to recorded interviews. The Client's Perception of the Therapist The final condition as stated is that the client perceives, to a minimal degree, the acceptance and empathy which the therapist experiences for him. Unless some communication of these attitudes has been achieved, then such attitudes do not exist in the relationship as far as the client is concerned, and the therapeutic process could not, by our hypothesis, be initiated. Since attitudes cannot be directly perceived, it might be somewhat more accurate to state that therapist behaviors and words are perceived by the client as meaning that to some degree the therapist accepts and understands him. An operational definition of this condition would not be difficult. The client might, after an interview, sort a Q-sort list of items referring to qualities representing the relationship between himself and the therapist. (The same list could be used as for Condition 3.) If several items descriptive of acceptance and empathy are sorted by the client as characteristic of the relationship, then this condition could be regarded as met. In the present state of our knowledge the meaning of "to a minimal degree" would have to be arbitrary. Some Comments Up to this point the effort has been made to present, briefly and factually, the conditions which I have come to regard as essential for psychotherapeutic change. I have not tried to give the theoretical context of these conditions nor to explain what seem to me to be the dynamics of their effectiveness. Such explanatory material will be available, to the reader who is interested, in the document already mentioned (see footnote 1). I have, however, given at least one means of defining, in operational terms, each of the conditions mentioned. I have done this in order to stress the fact that I am not speaking of vague qualities which ideally should be present if some other vague result is to occur. I am presenting conditions which are crudely measurable even in the present state of our technology, and have suggested specific operations in each instance even though I am sure that more adequate methods of measurement could be devised by a serious investigator. My purpose has been to stress the notion that in my opinion we are dealing with an if- then phenomenon in which knowledge of the dynamics is not essential to testing the hypotheses. Thus, to illustrate from another field: if one substance, shown by a series of operations to be the substance known as hydrochloric acid, is mixed with another substance, shown by another series of operations to be sodium hydroxide, then salt and water will be products of this mixture. This is true whether one regards the results as due to magic, or whether one explains it in the most adequate terms of modern chemical theory. In the same way it is being postulated here that certain definable conditions precede certain definable changes and that this fact exists independently of our efforts to account for it. The Resulting Hypotheses The major value of stating any theory in unequivocal terms is that specific hypotheses may be drawn from it which are capable of proof or disproof. Thus, even if the conditions which have been postulated as necessary and sufficient conditions are more incorrect than correct (which I hope they are not), they could still advance science in this field by providing a base of operations from which fact could be winnowed out from error. The hypotheses which would follow from the theory given would be of this order: If these six conditions (as operationally defined) exist, then constructive personality change (as defined) will occur in the client. If one or more of these conditions is not present, constructive personality change will not occur. These hypotheses hold in any situation whether it is or is not labeled "psychotherapy." Only Condition 1 is dichotomous (it either is present or is not), and the remaining five occur in varying degree, each on its continuum. Since this is true, another hypothesis follows, and it is likely that this would be the simplest to test: If all six conditions are present, then the greater the degree to which Conditions 2 to 6 exist, the more marked will be the constructive personality change in the client. At the present time the above hypothesis can only be stated in this general form–which implies that all of the conditions have equal weight. Empirical studies will no doubt make possible much more refinement of this hypothesis. It may be, for example, that if anxiety is high in the client, then the other conditions are less important. Or if unconditional positive regard is high (as in a mother's love for her child), then perhaps a modest degree of empathy is sufficient. But at the moment we can only speculate on such possibilities. Some Implications Significant Omissions If there is any startling feature in the formulation which has been given as to the necessary conditions for therapy, it probably lies in the elements which are omitted. In present-day clinical practice, therapists operate as though there were many other conditions in addition to those described, which are essential for psychotherapy. To point this up it may be well to mention a few of the conditions which, after thoughtful consideration of our research and our experience, are not included. For example, it is not stated that these conditions apply to one type of client, and that other conditions are necessary to bring about psychotherapeutic change with other types of client. Probably no idea is so prevalent in clinical work today as that one works with neurotics in one way, with psychotics in another; that certain therapeutic conditions must be provided for compulsives, others for homosexuals, etc. Because of this heavy weight of clinical opinion to the contrary, it is with some "fear and trembling" that I advance the concept that the essential conditions of psychotherapy exist in a single configuration, even though the client or patient may use them very differently. 4 It is not stated that these six conditions are the essential conditions for client-centered therapy, and that other conditions are essential for other types of psychotherapy. I certainly am heavily influenced by my own experience, and that experience has led me to a viewpoint which is termed "client centered." Nevertheless my aim in stating this theory is to state the conditions which apply to any situation in which constructive personality change occurs, whether we are thinking of classical psychoanalysis, or any of its modern offshoots, or Adlerian psychotherapy, or any other. It will be obvious then that in my judgment much of what is considered to be essential would not be found, empirically, to be essential. Testing of some of the stated hypotheses would throw light on this perplexing issue. We may of course find that various therapies produce various types of personality change, and that for each psychotherapy a separate set of conditions is necessary. Until and unless this is demonstrated, I am hypothesizing that effective psychotherapy of any sort produces similar changes in personality and behavior, and that a single set of preconditions is necessary. It is not stated that psychotherapy is a special kind of relationship, different in kind from all others which occur in everyday life. It will be evident instead that for brief moments, at least, many good friendships fulfill the six conditions. Usually this is only momentarily, however, and then empathy falters, the positive regard becomes conditional, or the congruence of the "therapist" friend becomes overlaid by some degree of facade or defensiveness. Thus the therapeutic relationship is seen as a heightening of the constructive qualities which often exist in part in other relationships, and an extension through time of qualities which in other relationships tend at best to be momentary. It is not stated that special intellectual professional knowledge–psychological, psychiatric, medical, or religious–is required of the therapist. Conditions 3, 4, and 5, which apply especially to the therapist, are qualities of experience, not intellectual information. If they are to be acquired, they must, in my opinion, be acquired through an experiential training–which may be, but usually is not, a part of professional training. It troubles me to hold such a radical point of view, but I can draw no other conclusion from my experience. Intellectual training and the acquiring of information has, I believe, many valuable results–but becoming a therapist is not one of those results. It is not stated that it is necessary for psychotherapy that the therapist have an accurate psychological diagnosis of the client. Here too it troubles me to hold a viewpoint so at variance with my clinical colleagues. When one thinks of the vast proportion of time spent in any psychological, psychiatric, or mental hygiene center on the exhaustive psychological evaluation of the client or patient, it seems as though this must serve a useful purpose insofar as psychotherapy is concerned. Yet the more I have observed therapists, and the more closely I have studied research such as that done by Fiedler and others (4) , the more I am forced to the conclusion that such diagnostic knowledge is not essential to psychotherapy. 5 It may even be that its defense as a necessary prelude to psychotherapy is simply a protective alternative to the admission that it is, for the most part, a colossal waste of time. There is only one useful purpose I have been able to observe which relates to psychotherapy. Some therapists cannot feel secure in the relationship with the client unless they possess such diagnostic knowledge. Without it they feel fearful of him, unable to be empathic, unable to experience unconditional regard, finding it necessary to put up a pretense in the relationship. If they know in advance of suicidal impulses they can somehow be more acceptant of them. Thus, for some therapists, the security they perceive in diagnostic information may be a basis for permitting themselves to be integrated in the relationship, and to experience empathy and full acceptance. In these instances a psychological diagnosis would certainly be justified as adding to the comfort and hence the effectiveness of the therapist. But even here it does not appear to be a basic precondition for psychotherapy. 6 Perhaps I have given enough illustrations to indicate that the conditions I have hypothesized as necessary and sufficient for psychotherapy are striking and unusual primarily by virtue of what they omit. If we were to determine, by a survey of the behaviors of therapists, those hypotheses which they appear to regard as necessary to psychotherapy, the list would be a great deal longer and more complex. Is This Theoretical Formulation Useful? Aside from the personal satisfaction it gives as a venture in abstraction and generalization, what is the value of a theoretical statement such as has been offered in this paper? I should like to spell out more fully the usefulness which I believe it may have. In the field of research it may give both direction and impetus to investigation. Since it sees the conditions of constructive personality change as general, it greatly broadens the opportunities for study. Psychotherapy is not the only situation aimed at constructive personality change. Programs of training for leadership in industry and programs of training for military leadership often aim at such change. Educational institutions or programs frequently aim at development of character and personality as well as at intellectual skills. Community agencies aim at personality and behavioral change in delinquents and criminals. Such programs would provide an opportunity for the broad testing of the hypotheses offered. If it is found that constructive personality change occurs in such programs when the hypothesized conditions are not fulfilled, then the theory would have to be revised. If however the hypotheses are upheld, then the results, both for the planning of such programs and for our knowledge of human dynamics, would be significant. In the field of psychotherapy itself, the application of consistent hypotheses to the work of various schools of therapists may prove highly profitable. Again the disproof of the hypotheses offered would be as important as their confirmation, either result adding significantly to our knowledge.