Barry A. Farber. Carl Rogers and positive regard

PhilosophyPodcasts.Org

Barry A. Farber (Columbia, Teacher's College), Jessica Suzuki (private practice, NYC), and Daisy Ort (Columbia, Teacher's College)

Understanding and enhancing positive regard in psychotherapy: Carl Rogers and beyond

The therapeutic relationship, more than any particular technique or intervention, is the key to therapeutic success. Positive regard is a crucial component of that relationship.

This book reconsiders the role of positive regard in contemporary psychotherapies.

Positive regard, along with the therapist's empathy and genuineness, is one of Carl Rogers’ three “necessary and sufficient” conditions for therapeutic change. However, positive regard is the least well-researched and most misunderstood of the three conditions. It has long been conceived as a potential ingredient in the formation and development of an effective therapeutic relationship, but many therapists in recent decades have considered positive regard a dubious ingredient, too oblivious to human frailty and malevolence, and too susceptible to a therapist's potential for collusion with patients’ defenses and resistance to change.

Written for a variety of psychotherapists, this book offers an investigation into the efficacy of positive regard by examining its history, evolution, misperceptions, criticisms, and value. The authors argue for a broader acceptance of the role of positive regard across diverse patients and therapies.

Table of contents

• Chapter 1: What Is Positive Regard and Why is it Important?
• Chapter 2: Positive Regard and Treatment Outcome
• Chapter 3: Re-Conceptualizing Positive Regard: Let Me Count the Ways
• Chapter 4: PR-Like Concepts Outside the Person-Centered Community
• Chapter 5: Positive Regard Outside Psychotherapy: Another Rogers, Personal Relationships, and Social Media
• Chapter 6: Positive Regard: Clients’ Perspectives
• Chapter 7: Positive Regard: Therapists' Perspectives
• Chapter 8: Clinical Examples of Positive Regard in Four Different Therapies
• Chapter 9: Positive Regard and Psychotherapy: Controversies, Criticisms, and Conclusions

Author bios

Barry A. Farber, PhD, is a professor of psychology and education at Teachers College, Columbia University. Dr. Farber received his PhD from Yale University.

Clinically, he has had training in behavioral, client-centered, and psychodynamically oriented psychotherapies. His research and scholarly interests are in the areas of psychotherapy process and outcome, the impact on the therapist of working in psychotherapy, the development of psychological-mindedness, and the way in which interpersonal disclosure is influenced by emerging technologies.

Dr. Farber was director of training in the clinical program at Teachers College for 21 years, from 1990 to 2011, and recently, from 2014, reassumed that position. He's currently the editor of the Journal of Clinical Psychology: In Session. He's also on the Executive Committee of Division 29 (Psychotherapy) of APA.

Jessica Y. Suzuki, PhD, is a client-centered therapist trained in a relational psychodynamic approach. Dr. Suzuki received her PhD from Columbia University Teachers College.

She believes that client outcome depends on the quality of patient-therapist collaboration and on therapeutic strategies. She incorporates CBT strategies to scaffold behavioral change and draws on mindfulness and experiential approaches to strengthen self-compassion, insight, and healing.

Daisy Ort is a fourth-year doctoral candidate in the clinical psychology PhD program. Her research experience with the Psychotherapy, Affirmation, & Disclosure Lab began as a masters student at Teachers College in 2013.

Prior to beginning her doctoral studies, she worked within New York City’s mental health and legal systems conducting research at a criminal justice nonprofit, co-leading weekly support groups at federal jails, and facilitating forensic psychological evaluations for immigration purposes. As a graduate student, she is interested in better understanding relational aspects of psychotherapy across different contexts.

Podcast blog

In philosophy, Carl Rogers is known for (1) his debates with B.F. Skinner; (2) his dialogues with Martin Buber; and (3) his independent development of phenomenology. (Only after developing his ideas did he learn that this approach--what he was doing--was in Europe called "phenomenology").

Rogers also developed what he called "positive regard," (PR) which grew out of John Dewey's work on valuation, especially Dewey's concept of "prizing."

In this podcast, I interview Barry A. Farber about his new book (co-authored with Jessica Suzuki, and Daisy Ort) which is an up-to-date and comprehensive presentation of PR, its history, theoretical underpinnings, interscholastic variations, empirical support, and practical applications. This book is primarily directed towards practitioners and theorists of psychotherapy, as the interview with Dr. Farber will show; it will be featured in our forthcoming series on psychotherapy podcasts.

For philosophers, however, the book and the interview may also be of interest, especially for philosophers interested in phenomenology, intersubjectivity, talk therapy, and valuation.

The remainder of this blog entry provides additional background for philosophers who may not be familiar with Rogers' work.

Rogers started his career with a doctorate from teacher's college and then practical work as a psychologist at the Society for the Prevention of Cruelty to Children in Rochester, NY. Outside of his clinical work, he started writing books and then transferred to academic work at the University of Wisconsin and the University of Chicago.

Although appreciative of Freud's writings, Rogers attacked the doctrinaire Freudians of the American Psychoanalytic Association who dominated American postwar psychotherapy. He was a committed empiricist who developed testable versions of his theories. His primary concern was: what works in talk therapy.

Rogers acknowledged that he learned the essence of his psychotherapeutic technique from two people primarily. First: Otto Rank, once one of Freud's inner circle who came to the United States and found significant influence in schools of social work. Rogers was completely UNinterested in Rank's theoretical work (regarding, e.g., birth trauma), but he was fascinated by Rank's ideas on psychoanalytic practice.

For example, Rank de-emphasized intellectual understanding, and instead emphasized the therapeutic use of empathy. Rank wrote, "What prevents us from a correct ... therapeutic understanding is the desire to understand intellectually. Correct understanding is one of empathy, ... whereas intellectual understanding is ... a compelling of the other to our own thought, our own interpretation." Also, he wanted to "put[] the whole emphasis of the process on emotional, instead of intellectual, experience."

Rank's name is also associated with "Will" therapy. He emphasized that in the therapeutic situation, the patient in some sense "willed" the illness (gained a "substititute satisfaction" from the illness [today we, might say, a "jouissance"], one that the patient would resist relinquishing. For example, Rank wrote that, "As a result of my experience, I found ... that the illness is nursed by the patient in order to withdraw from life ... [I]t is self-willed, a sort of [personal creativity that finds] expression only in this negative, destructive way."

Finally, Rank is well-known for flipping the hierarchy in the therapy situation. "The whole [traditional, "Freudian"] psychoanalytic approach is centered around the therapist, who is doing the research and the explaining on the basis of what he knows. Real therapy has to be centered around the client, his difficulties, his needs, his activities." And, succinctly, "The therapist must not take the part of authority of any kind, but must be satisfied with the role of an ego helper (assistant ego)."

The second primary influence on Rogers' technique was the philosopher Jessie Taft. Taft wrote one of the earliest dissertations on the feminist movement; her 1913 University of Chicago thesis (advised by George Mead) was The Woman Movement from the Point of View of Social Consciousness.

As a woman, Taft was unable to receive an academic position. She went to work in the "mental hygiene" movement with Virginia Robinson who would become her life partner and her career partner. As life partners, Taft and Robinson adopted two children and lived in a "Boston marriage." As career partners, they founded the school of social work at the University of Pennsylvania; they also are known as the founders of a school-of-thought within social work, the "functional" school.

In official versions of the history of American talk therapy, Taft is regularly overlooked (again, presumably because the link is made from male Rogers to male Rank), but Rogers acknowledged that his personal interaction with Rank was limited, and it was truly Taft and her team who actually taught their method hands-on.

There are, of course, many gifted therapists who never wrote down their method, or published their method as a book. Taft, however, was a professor, scholar, translator, and psychoanalyst. (She translated Ranks's major works, and she chose Rank as her training analyst).

A strong case could be made that the first book in the Rogerian tradition was Taft's 1933 The Dynamics of Therapy in a Controlled Relationship. Originally, the client-centered (Rogerian) approach was called either "nondirective" or "passive" therapy (meaning that the therapist was "passive" as in not active, not the center of attention in the therapy).

Taft originally attempted to work as a psychotherapist, but she felt her attempts were failures. Thus, she went to look for a training analyst (and chose Rank). Her description of her first session with Rank is telling:

"When I finally came to my first hour with Rank, while consciously submissive, afraid, and fully aware of my ignorance of psychoanalysis, my underlying attitude was far from humble. I was, after all, a psychologist. I had some knowledge of myself and my problems. I had achieved a point of view psychologically. If there was anything in my unconscious in terms of buried memories, I would have to be shown. And so the battle was joined; but I soon found that it was a battle with myself. I was deprived of a foe.

"It took only two weeks for me to yield to a new kind of relationship, in the experiencing of which the nature of my own therapeutic failures became suddenly clear. No verbal explanation was ever needed; my first experience of taking help for a need that had been denied was enough to give a basis for the years of learning to follow."

The Rank-Taft-Rogers approach has also been called "relationship" therapy--in that the therapy provides a new kind of (disciplined) relationship, one which serves as fertile soil for the client to grow from his/her own action.

Excerpts from Taft (1933)

"Therapy as it relates to the balance of forces in the organization of personality has always been of prime importance to me, but my concept of what such therapy involves has undergone a complete revolution in the past twenty-five years. It has developed from the notion of a reform of the 'other' through superior knowledge of life and psychology, a concept closely allied to that of scientific control in the field of emotions and behavior, to my present acceptance of therapy as presented in this volume, a therapy which is purely individual, non-moral, non-scientific, non-intellectual, which can take place only when divorced from all hint of control, unless it be the therapist's control of [herself] in the therapeutic situation."

"The word 'therapy' is used instead of 'treatment' because in its derivation and in my own feeling about the word, there is not so much implication of manipulation of one person by another. To treat, according to the dictionary is to apply a process to someone or something. The word 'therapy' has no verb in English, for which I am grateful; it cannot do anything to anybody, hence can better represent a process, going on, observed perhaps, understood perhaps, assisted perhaps, but not applied.

"The Greek noun from which therapy is derived means 'a servant'. The verb means 'to wait'. … No one wants another to apply any process to the inmost self, however desirable a change in personality and behavior may seem objectively."

"Over [the client's use or non-use of the therapeutic relationship,] I have no control beyond [1] the genuineness of my understanding of the difficulty with which anyone takes or seeks help, [2] my respect for the strength of the patient, however negatively expressed, and [3] the reality of my acceptance of my function as helper not ruler."

"As I conceive it, the therapeutic function involves the most intense activity but it is an activity of attention, of identification and understanding, of adaptation to the individual's need and pattern, combined with an unflagging preservation of one's own limitation and difference.

"[Any] preconceived idea of what the interview should sooner or later bring forth, tends just as much to control and domination of the client as if [the caseworker] had tried [deliberately] to reform [the client's] habits or his morals. Very few case workers ever realize [this], because if they did they would be greatly at a loss as to what function remains for them." "One might fairly define relationship therapy as a process in which the individual finally learns to utilize the allotted hour from beginning to end without undue fear, resistance, resentment or greediness ... In so far [as] he has learned to live, to accept this fragment of time in and for itself, and strange as it may seem, if he can live this hour he has in his grasp the secret of all hours, he has conquered life and time for the moment and in principle."

"In the last analysis therapy as a qualitative affair must depend upon the personal development of the therapist and [her] ability to use consciously for the benefit of [her] client, the insight and self-discipline which [she] has achieved in [her] own struggle to accept self, life and time, as limited, and to be experience fully only at the cost of fear, pain, and loss. ... To make case work therapeutic, incidentally or deliberately, one must be a therapist and only to the extent that this is true are the relationships one sets up therapeutic … rests upon strength of will, freedom to feel, and an ability to lend oneself to the use of the other … in addition to skill. … [p. 22] to develop or accept the self which is required by her job, a self with real strength to be utilized therapeutically by the client.

"If I had followed out my own theoretical interest, I should have pursued some of the biological material introduced by John, his symbolic use of the rug in a birth struggle, his references to toilet functions and breast, his use of the tent, etc. But I am convinced that in so doing I should have lost sight of and interfered with the creative use of a present experience, which I had only to understand and respond to intuitively not to interpret or investigate in terms of my own intellectual curiosity. To pursue the symbol may be science. It is not therapy."

Podcast Transcript

August Baker: Welcome to Psychotherapy podcast. This is August Baker. Psychotherapy podcast is where we interview leading scholars about their books on psychotherapy. Today, I'm talking about the book, Understanding and Enhancing Positive Regard in Psychotherapy: Carl Rogers and Beyond. It's by Barry A. Farber, Jessica Y. Suzuki and Daisy Ort. Today, I'm privileged to speak to Barry Farber. He's a professor of psychology and education at Teachers College Columbia University. His research interests include the nature and consequences of therapist provision of positive regard, the extent to which patients, therapists, supervisors, and supervisees honestly disclosed to each other, and the ways in which individuals construct and evoke mental representations of others. Previous books include Secrets and Lies in Psychotherapy, Self-disclosure in Psychotherapy, which I highly recommend, the Psychotherapy of Carl Rogers, and Rock and Roll Wisdom. He recently completed a term as editor of the Journal of Clinical Psychology in Session and maintains a small private practice of psychotherapy. Welcome, Barry. Barry A. Farber: Thank you. August. Nice to be here. August Baker: To start off, tell us something about your two co-authors rather than have me read the blurbs. Barry A. Farber: For sure. Jessie Suzuki is a recent graduate, doctoral graduate, of our clinical psychology program in Teachers College who's now in private practice in New York. Actually, teaches for us at this point our, family therapy course. Her dissertation was about positive regard and she'd been working with me for years on issues surrounding positive regard. Daisy Ort is a current fourth year doctoral student in our program, applying for internships. Another very talented doctoral student who's also been running one of the research labs on positive regard. Both of them are wonderful additions and contributors to this book. August Baker: Great. Thank you for that. I want to start off, generally. Tell us about the book, what it covers, its intended audience, and also something about the history of the Positive Regard Lab, which I was interested in. Barry A. Farber: Some of your listeners, perhaps most of your listeners, will know Roger's posited three necessary and sufficient ingredients of psychotherapy. To be more technical, actually posited more than that, but three fundamental conditions, which was the therapist provision of empathy, positive regard, and genuineness/transparency/authenticity. The other two, meaning the empathy piece in particular and, to a certain extent, the authenticity piece had been and continues to be fairly widely researched. Especially, the empathy piece. Books, research articles, conference presentations, et cetera. For some reason, positive regard was neglected in the history of psychotherapy research. Maybe, 10 years ago or so, we decided to look at that particular variable a little more closely. Rogers considered only the ways in which the client received positive regard is what was important. That is, it wasn't, from his perspective anyway, it didn't really matter what the therapist was providing what mattered was what the patient... Well, actually he preferred the word client, the nature of what the client was receiving. Over the years we started looking at the ways in which clients most preferred, that is what kinds of positive regard they most preferred. We expanded greatly the classic measures of positive regard to include other potential aspects that clients might regard as positively regarding. We also looked at the ways in which therapists thought that they most often provided positive regard and that which they thought the most salient aspects of positive regard were. We started looking at some cultural aspects of positive regard. That work is really central to what these labs are continuing to do. Now, one of the peculiarities of that positive regard or, actually, two of them. Is the extension, which Rogers never really articulated what positive regard looked like in psychotherapy. That he thought of it as an attitude and he used multiple synonyms for positive regard, non-possessive love, acceptance, liking among others. August Baker: Prizing. Barry A. Farber: The ways in which the classic ways of actually assessing positive regard was tremendously confounded with empathy. In fact, when Rogers gave a couple of examples of positive regarding his case history it was, essentially, empathy. One of the other pieces we try to look at was to see whether positive regard could be defined and whether it was manifest in both patients and therapists views as more than empathy. What else it might consist of other than the therapist's ways of accurately hearing what the client had to say. Those are some of the activities that the lab has been doing for about 10 years. August Baker: Yeah, that's interesting that empathy was confused with positive regard. I think Kohut would say that empathy is neither positive nor negative. You can understand what drives someone and understand their perspective and then there's a question about whether you're going to use that for good or for the ill of that person. Barry A. Farber: A hundred percent. August Baker: Right. Barry A. Farber: Of course, the other piece that researchers have tried to distinguish around empathy is the whole notion of intellectual empathy versus emotional empathy. Do you understand or what I'm saying? Or do you really feel on a more visceral level what I'm trying to convey? August Baker: Right. Barry A. Farber: The other piece that you and I, for your listeners, have been writing each other about is the extent to which Kohut did or didn't benefit from being at least in proximity to Rogers, even though he never quite acknowledged that. August Baker: He didn't. The Strozier biography of Kohut says that he never mentioned him in his writing and it seems that he didn't really understand what Rogers was saying. He seemed to think, from my understanding of the Strozier biography of Kohut, there were two times where Kohut mentioned Rogers peripherally. He expressed it as though Rogers were asking people to free associate, but then not add any interpretation. Barry A. Farber: I think, the last part of the sentence is true. He didn't add interpretations, very often. Although, like virtually all psychotherapists he wasn't pure in his theoretical implementation. He did occasionally interpret, he did occasionally ask leading questions. Yeah. The other thing you and I have communicated about too before this podcast is the extent to which, in particular, I feel, that relate contemporary relational dynamic therapist having given Rogers is due for emphasizing the extent to which the relationship is fundamental, foundational even for the provision of good psychotherapy. You have books about contemporary dynamic therapy, even a book called Relationality by Stephen Mitchell, one of the founders of Contemporary Relational Dynamic Therapy. He never even mentions Rogers and the book called Relationality. August Baker: I like the distinction between being reparative or being skeptical, paranoid. The paranoid way to say would be that the psychoanalytic tradition is so arrogant that they don't want... The thought of Rogers as a popularizer and we are not even going to read him, because we don't think there's anything there. The more repetitive way would be to say each of these traditions really only reads the people in their tradition. Barry A. Farber: Every tradition is so insular, it's a hundred percent sure. What's ironic, of course, is the extent to which most, especially experienced therapists, now regard themselves as integrative. It's a funny integration. It's like, "I'll utilize multiple aspects of multiple traditions, but I'm not going to read bunch about any of them." August Baker: Right. Exactly. Often my impression, a very strong emotional loyalty towards their particular school or their particular... Yeah. Barry A. Farber: Well, it's only relatively recently, in the last couple of decades, that the American Psychological Association has insisted that programs become more diversified in the theoretical orientations that they're offering. That is in the eighties, nineties, you could essentially have a doctoral program in clinical or counseling psychology and offer one theoretical position. Now, APA is more or less insisting that you offer your students multiple ways of understanding clinical phenomena. Most new students, to the point, is most new students are at least being... Understanding, getting some awareness of the ways that... Even, say, at Teacher's College, which is still primarily a psychodynamic tradition, our students are learning a great deal about cognitive behavior therapy, about IPT, interpersonal psychotherapy, and that's true multiple places across the country. August Baker: Let me read a... This is an endorsement, which I think covers nicely what the book covers. This is from Adam Horvath of Simon Frazier University. He says, "Under one cover, this book offers a rich and thorough review of the history and philosophical roots of positive regard, the related empirical research," and I'll add that includes both quantitative research and qualitative research, "and a practical guide for clinical uses. It provides both an inside, within the client centered tradition or the Rogerian tradition and broader pan theoretical perspective." I'll add there that the book goes into how other traditions have developed these concepts, whether we're talking about Winnicott or Kohut, or whether we're talking about back in cognitive behavioral or Miller in Motivational Interviewing. Even when they have... This book will cover how those traditions have developed similar concepts and how they're different. Barry A. Farber: Yes. August Baker: Then continuing with Horvath, "The authors offer a deep appreciation of the value of PR and, at the same time, also carefully delineate the limits and challenges associated with the concept." He says, "This outstanding book is a rare combination of scientific rigor and tried clinical wisdom in an accessible and engaging format. An essential item in the library of every psychologist." I thought that was very true. Barry A. Farber: Well, thank you and thank you, Adam. August Baker: Yeah. I didn't think you would want to say that, so I thought I should read that. Let's talk about it. Barry A. Farber: There should be a limit to everyone's narcissism, but thank you for offering that. August Baker: Let's talk about what is positive regard in one sense? Well, you could look up positive, you could look up regard, that's what it is, but it's really a term of art. It's more than just those two words. Barry A. Farber: One of the complications I think you're getting to, which I'm a good thing to speak about, is Roger's confusion. That's probably a little bit too leading. Rogers wasn't clear throughout his career and whether positive regard was really one attitude or two or one omnibus attitude. What do I mean by that? In the beginning, he was mostly about positive regard, which by the way was a term offered by one of his doctoral students that he adopted, it was for the most part acceptance. That is the therapist was to be nonjudgmental and accepting of virtually everything that the client had to say. That said, it wasn't just acceptance, because they also used words like support, caring, liking. There was often an added emotionally, positively laided emotional piece to it. To accept something neutrally is distinctly different then me as a therapist letting you know that not only do I accept what you say, but I care for you, I support you. I like you. Non possessively loving you. At times, including some ways assessing positive regards. Barrett-Lennard Scales originally had two positive regards scales that try to distinguish between these two. Historically, they've melded into one piece in part, because of the quirk, I think of the Bergen and Garfield Handbook of Psychotherapy and Behavior Change. Sort of the Bible of psychotherapy research. Where the success of addition talked about acceptance and affirmation as one chapter. August Baker: Right. Barry A. Farber: There are times where the purer Rogerian's have pushed back against positive regard as including an element of affirmation. Other times, particularly non-classical person center theorists, as well as other psychotherapy researchers have suggested no positive guard needs to be seen as not just acceptance, but as having this positive valence attitude of caring for. That's the confusion in the literature. August Baker: Very interesting. You can see that you could have one of those and not the other. Barry A. Farber: A hundred percent August. August Baker: You could be very caring about someone, but really hate it when they tell you something about themselves. You can be... Actually, it's pretty easy to be accepting of someone that you don't care about. Right? Barry A. Farber: Right. August Baker: Yeah. You can see how they're different. Barry A. Farber: You're right. Now, contemporary, most not all. Contemporary theorists with who still adhere to believe themselves as person centered have more or less adopted the more omnibus definition and positive regard. Some of the research outside my lab have pushed back hard against that. "No. That's not what Rogers meant. That's not what positive regard is." Positive regard is more or less acceptance. If you add an element of evaluation you're no longer talking about positive regard and have actually pushed back against the term. It's really not positive regard they say. That's an unfortunate term that Rogers adopted from his, as I said, his student was actually Stendhal. You don't have suggested, the term has sort of lost its essential meaning, because now we're including too many attributes around it. I think not by the way, but there's always people within every tradition who are more classical, and traditional, and who don't like central terms to be adopted for contemporary reasons... August Baker: Right. Barry A. Farber: ...or somehow expanded in their meaning. August Baker: In one of the Rogers classic articles, and your book talks about this, he uses the word prizing. Barry A. Farber: Prizing. Yeah. I forgot that. Absolutely uses the word prizing. You're 100% right. Of course. August Baker: That's really supportive and... Barry A. Farber: 100%. That's part of this other secondary definition. If I prize you it's more than accepting you. August Baker: Yeah, that's right. Prizing, it's clearly emotional. There's also a sense in which it's something you can do. You can cultivate. It's not just, I don't know, I either like you or I don't. It's something that it has a bit of an action within it. Barry A. Farber: I think I agree with you entirely. I can make statements that suggest that I affirm, prize, support your actions. I'm proud of you. August Baker: Right. Barry A. Farber: I've done well. I'm pleased with the work we're doing together. I think that was an appropriate behavior that you showed last week. August Baker: One really, as you said earlier, one of the things Rogers claimed was that he didn't want to impose any theory on people. Barry A. Farber: Right. Though he did. August Baker: It's like a respecting a person's autonomy. Barry A. Farber: Right. August Baker: Is that part of... Do you put that under positive regard also? Or is that sometimes considered there? Barry A. Farber: No, I do. It's one of the aspects. August Baker: Right. Barry A. Farber: Except a person's... Rodger's predated the army, "Be all that you can be," but that was his notion. August Baker: Right. Barry A. Farber: Yes and no, "Be all that you can be," but he also, of course, as you know, believed that if he showed you his total acceptance and believed in your ability to find your own way that you would in fact find a way toward being a virtuous person. August Baker: Right. Yeah. I think he had a view, as my understanding, which is quite common today, I think, which is that yes, people can be terrible, and vicious, and cruel, but it's usually coming from a defensive place and that actually underneath that you wouldn't find it. It's coming from a place of insecurity or defensiveness. Barry A. Farber: In that regard, he aligns himself to a great degree with psychoanalytic tradition. That the object relations people suggest that aggression is not particularly a primary drive as Freud would have it, but rather reaction to people not getting what they need. August Baker: One of the things- Barry A. Farber: Lack of interpersonal caring from others leads to aggressive stance rather than it being a primary motive in life. August Baker: Right. The idea was he's not saying I'm okay with your aggressive behavior or your aggressive thoughts. He's saying, I can accept it and then he has this idea that rather than criticizing you accepting you will get you to start to change. Barry A. Farber: Exactly. It's roughly analogous to the parental stance. To the good parents who give the message to their kids, I don't like what you're doing right now, but I'll always love you. August Baker: That's been misinterpreted a lot, of course, because people don't read Rogers and they think he's saying I like everything... Barry A. Farber: What you do. Right. You and I agree entirely on this. August Baker: Okay. Barry A. Farber: Rogers would actually be asked that a fair amount in small groups. How can you accept someone who's openly racist? For example. He would give the answer that you and I are deliberating on now, which is I don't accept the racism I accept the person and, ultimately, to the extent that the person feels accepted by me he will have not only a better view of him/herself, but of others in the world as well. August Baker: He said it about himself also. He says, I find that the first way for me to change is to accept myself the way I am. Barry A. Farber: Exactly. August Baker: Yeah. Barry A. Farber: Right. August Baker: This is a really current issue, because a lot of people who are psychotherapists would be a really heightened, have heightened, awareness of racism, for example. The question is what is your advice to someone who is treating a patient who's racist and wants, and feels it's their responsibility to respond to this, not just acquiesce to it. I can see it would be really frustrating to think, "Well, if I accept it eventually the person may come out of it themselves." It's not immediate. And it seems to be... Barry A. Farber: I think you're a hundred percent right. There's a certain irony in the extent that ultimately that working from a Rogerian person-centered perspective, the person would change his/her point of view. The irony I'm pointing to is that Rogers rarely, if ever, did long term work. Especially, the whole second half of his life. It was mostly demonstration interviews. He also remembered, and it reminded your audience, that a good deal of the last few decades of his life he spent with what we would now call social justice pieces. Working in South Africa, working in Northern Ireland trying to get warring factions to speak to each other by hearing and accepting your points of view. The notion is consistent with what you're suggesting. That once a person feels heard, once a person feels truly heard, that he or she can begin to let go of some of the anger and frustration. That ways, it's a psychoanalytic piece too. That the psychoanalyst who believe that underneath anger there is always... There's inevitably sadness in that. What's manifest is not really what we need to get to, but the sadness underneath the anger. Rogers of course doesn't hold... He never liked psychoanalytic meta psychology, but implicitly he believes something like that. That if you go beyond the surface of what a person was saying by accepting the person and letting the person consistently know that I care about you, I support you, that the person would give up the more aggressive, mean spirited pieces of both... Toward themselves, toward any self-defeating behavior, as well as toward rank or toward others. Did it work? To a certain extent. People who are at the conferences in South Africa have written reports that people began to talk to each other with more respect after working with Rogers. Did it lead to any long lasting changes? Hard to know. There's no follow... 10, 20 year follow ups on his social justice work. Not enough work, in general. Not just in person center Rogerian tradition, but this too. One of the limitations of psychotherapy research is how little follow up work we've done, whether psychotherapies affects when door 1, 5, 10 years later. What we're left with. What's the half life of psychotherapy person centered or otherwise? August Baker: It occurs to me that one area where.... Again, I don't know how much credit is given to Rogers, but this sounds also very much like a technique or an approach to couples counseling or family work. Where the therapist wants to get the people to be heard. Barry A. Farber: A hundred percent August. To be heard. In a somewhat similar fashion, there are people who suggested all of Rogers conditions really could be consolidated into one, which is the therapists need to be responsive, and respectful, and that these are all variations on the same thing. That people want to be heard. August Baker: If you can, even provisionally, bracket your own views on it, and at least understand it, and show that you do that somehow leads to something positive for Rogers. Barry A. Farber: I couldn't have said it better. August Baker: Let's talk about the empirical results, because Yalom has this quote expresses his frustration with empirical work. Not that he doesn't value empirical work, but that he finds it frustrating. He says, "In psychotherapy research the precision of the result is directly proportional to the triviality of the variables studied." Barry A. Farber: Isn't that wonderful? I didn't know that quote, but I love it. August Baker: You're picking here a variable that is very difficult to capture. Barry A. Farber: Right. August Baker: The other thing that Yalom says is look, this is the nature of the field where we can't be looking for precision. We have to live in uncertainty. Still, it would be nice to be able to say no to someone who says, "Oh, positive regard. There's no evidence that correlates with anything." Barry A. Farber: Actually, there is good evidence. August Baker: That's what I'm saying. It's nice that... Yeah. Barry A. Farber: There are. At this point, there's a hundred or so studies that taken together... I'm not going to get into the statistical piece, but you throw all the studies into a blender, and you look at outcome, and there's a moderate correlation between positive regarding and outcome. To take in a larger look, there's only positive correlations between any variable in outcome. Probably, the largest correlation is between the alliance and outcome. Even that is in the high point, maybe 0.28, something like that range.Any variable taken by itself only is accounting for a small proportion of the variance in outcome. I like Yalom's quote. Let me get to your point. August Baker: Yeah. Barry A. Farber: What Yalom is suggesting, and Yalom and Rogers actually liked each other and respected each other's work, they're suggesting that the way that outcome is measured in psychotherapy research is almost always in terms of reduction in symptoms. Saying the brief symptom inventory or multiple other variations on that. That doesn't per Rogers, per Yalom measure what they're doing. It's not about reduction in symptoms it's something far more humanistic and existential than that. It's more about how the person regards him or herself. It's the way that you accept yourself. It's the way that you accept others. It's the way that you connect with others. I think Yalom and Rogers would agree as saying the way that outcome is measured is not what I have in mind about what psychotherapy is about. August Baker: But I want to do the best I can. Barry A. Farber: Absolutely. August Baker: The other thing that a lot of people may not know about Rogers was that he was very committed to empirical research. Barry A. Farber: There are a lot of people who think Rogers is the first significant psychotherapy researcher. As you know, the first person who made his recordings available to the research community. August Baker: Right. Barry A. Farber: The first fully published transcript. August Baker: Right. Yeah. He was just very committed to... People think of, "Oh, he's touchy feely," but he was... Barry A. Farber: No he was a theorist. August Baker: Yes. Barry A. Farber: He was very open to doing psychotherapy research. He really wanted to identify the elements that worked. He specified what he thought were the necessary and sufficient conditions, which by the way are probably not neither necessary nor sufficient, though they were significant. August Baker: He certainly framed it in a testable way. Barry A. Farber: A hundred percent, August. Couldn't agree more. He was a... Right. Which by the way is in great contrast to Freud, that I don't have the exact quote, but Freud is often cited as one person interested in doing hard research on Freudian psychoanalysis in the turn of the 20th century. Freud saying something like, I guess it couldn't hurt, but it doesn't matter what you find, because I know I'm right. August Baker: Right. Also, those concepts were not... He didn't have an eye at all on testing. Melancholy is aggression turned inward. What are you going to do with that? Barry A. Farber: Not much. August Baker: Yeah. Here's the thing. We can say there is evidence... Barry A. Farber: There is. Right. August Baker: ...that there is hopeful. The question is now, if you have a therapist who is not feeling positive regard... Barry A. Farber: What do you? August Baker: ... with their patient do they... Barry A. Farber: Fake it. August Baker: ...try to cultivate it? Do they fake it? Do they...? Roger's response would be, well, they need to accept it in themselves and that's the first step. Barry A. Farber: That's right. August Baker: But it's not... Barry A. Farber: I have a whole section on the book as that deals with this. What happens when the mandate to be positive regarding seems to conflict with the mandate to be authentic. August Baker: Yes. Right. Barry A. Farber: That's a incredibly hard issue. I think the way that you just posed it now is essentially what Rogers would say. I'm going to try to accept my sense of what you're trying to say here, but Rogers is quoted at least once as saying something on the order of "If I really didn't like the client. I would hope that I would have the courage to say as much and to be authentic in my interactions with that client." In one sense, that's virtuous. In another sense, there's something ironic about it, because like Will Rogers, he never met someone he didn't like. August Baker: Right. Barry A. Farber: It was never tested. August Baker: It was easy. Right. Barry A. Farber: Right. You have all these clients and he has probably more than any other therapist living or dead, he has more case studies available to study than any other person, but there's essentially no evidence of him being angry or disappointed in a client. August Baker: Right. Except we do have this one case. I don't know. Did you get a chance to read the description I sent you? Barry A. Farber: Yeah. August Baker: For our listeners, there was this one case which was really affected Rogers. Barry A. Farber: Very much so. August Baker: Could you describe it in your terms? I didn't know what to make of it. Barry A. Farber: Well, yeah. Again, for your listeners, August and I had this wonderful email correspondence about this case. You're right, the paragraph before I'd forgotten that and saying... He did struggle mightily. In fact, he struggled so mightily working with this woman who he regarded a schizophrenic that following that he did two things. He went into treatment and he also took a long vacation... August Baker: Right. Barry A. Farber: with his [inaudible 00:30:11]. He was incredibly upset with himself for not being able to be helpful to this patient. He really didn't look forward to working with her and felt he was not a good therapist, because of that. He became quite self-deprecating. Both you, August, and I agree that he probably misdiagnosed his patient based on her presenting symptoms. Virtually everyone now would not diagnose her as schizophrenic, but rather borderline. Although very technically, we talked about borderline patients as early as Robert Knight and Manager Clinic in the 40s, people really weren't talking much about borderline patients when he was writing about his work with her in the 50s. He misdiagnosed her and now we would have a much greater understanding of why he was struggling with her. She was pushing the boundaries. She was showing up in his doorstep without having appointments. August Baker: Going to his house. Yeah. Barry A. Farber: Yeah. What I... Doorstep, literally. Not as professional room. August Baker: Right. Barry A. Farber: His personal, yeah, exactly, home. He didn't keep the boundaries that we would now regard as fundamental in working with someone who would be diagnosed with borderline personality disorder. There's a bit of a glib statement that people working in inpatient hospital units have uttered over the years, including even 40 years ago when I was an intern. 45 years ago. Something like if the hospital ward feels absolutely overwhelming and psychotic it's not because there are schizophrenic patients on the ward. It's because there are borderline patients on the unit who tend to push buttons, and push boundaries, and be provocative. This is one of those instances where Rogers, as you know, didn't like diagnoses. Really believe in diagnoses. In this case, had he understood more about diagnoses, including what patients diagnosed now with borderline personality disorder were presenting, he would probably have a better sense of what he didn't do sufficiently well. You're right, absolutely. That was an important case in which he didn't like. He didn't say he didn't like it, but he did say he didn't like himself for... August Baker: True. Barry A. Farber: ...for not being a good enough therapist for this person. He certainly implied that he didn't enjoy working with her and he almost escaped from her quote clutches. August Baker: Right. Barry A. Farber: He stopped working with her. He did, to his credit, reassign her to someone else in his clinic, but... August Baker: Right. Barry A. Farber: Yeah, she certainly pushed his buttons mightily. August Baker: Right. He says, "I started to feel it was a real drain on me. Yet, I stubbornly felt that I should be able to help her..." Barry A. Farber: That's right. August Baker: "...and permitted the contact to continue long after they had ceased to be therapeutic and involved only suffering from me. I recognized that many of her insights were sounder than mine and this destroyed my confidence in myself. I got to the point where I could not separate myself from hers. I literally lost the boundaries of myself." Barry A. Farber: Terrible. August Baker: He says, "This situation's best summarized by one of her dreams in which a cat was clawing my guts out, but really did not wish to do so." Does this have anything to do with positive regard with a borderline patient? Is the positive regard to stimulating or...? Barry A. Farber: It certainly can be. There's another section of the book that speaks about, for some patients who've grown up feeling is that the only thing they deserve is hurt the positive regard feels disingenuous. They don't deserve to be positive regarded. It's a little more complicated than, actually, the sentence I just made, because, as you know, the primary defense mechanism for borderline patients is splitting. On the one hand, borderline patients want to idealize and be idealized, but on the other hand, it doesn't take much for them to turn on you. When you go from being idealized to being completely criticized and being seen as worthless. Particularly, for novice therapists to working with borderline patients often there's a vacillation between wanting to save them. I'll be the first person in a long line of people, long line of therapists, to work effectively with this person diagnosed with borderline person disorder. Versus, I can't tolerate the feelings that I have for, I'm going to use female pronoun here, for her or for myself. Or Rogers feeling totally ineffective. Yeah, I think one has to be very careful in what one offers to borderline patients. Almost from many theoretical perspective. August Baker: Right. Barry A. Farber: Positive regard, one has to be particularly careful about, one accepts the patient. In fact, borderline patients need to feel accepted, because per almost any theoretical tradition it's the fact that they were, many anyway, were abused, traumatized, invalidated, in Marsha Linehan's terms growing up. The notion of the quick digression, Marsha Linehan's notion of validation has much in common with Roger's notion of positive regard. Yes, it's important to validate why a borderline patient would act as, I'm going to use female pronoun here, she does or would, but one has to be very careful about going over the top and being overly supportive, because then you're setting up the stage for the person always wanting that. Particularly, patients within this diagnosis are going to feel deprived if you're not sufficiently giving them that and push for more. I think your point is, and it's very well taken, I do note this in the book, we I should say, because I have authors, of course, note this in the book. Positive regard like almost any variable needs to be offered in part with a notion of who this person is diagnostically, terms of identity, understanding there are cultural differences. All of these need to be taken into consideration. One should be thinking about not just that I'm accepting, but what forms of positive regard am I offering at this time, to this person with what potential consequences. I ask people to be mindful. I think in positive regard is incredibly significant and important virtually all forms of psychotherapy. Again, it's an attitude that needs to be thought about in terms of dosage, timing, the exact type one is being offered. Now we're in the realm of what Bill Stiles calls responsiveness. One has to think about what's the best way of offering, what kind of intervention, at what point in the therapy, for this particular patient. August Baker: I see that here's a case where we separate the acceptance and the support. Right. Barry A. Farber: I think that's right. August Baker: Something about the support, that patient wanting to go into his house. Barry A. Farber: I accept the fact that you want to do this... August Baker: Right. Barry A. Farber: ...but I simply can't allow it. I certainly don't support your behavior in this regard. August Baker: Right. Barry A. Farber: No positive reinforcement for your doing it. I'm not seeing you. August Baker: Right. The caring, liking, it's like, "Oh my gosh. You care and like me, we should be living together." Is that another possibility. Barry A. Farber: That's certainly true of borderline patients who will continue, of course, as you know, to push boundaries. Right? I accept the fact that you want this, but my authentic self, and my need to protect myself, and protect the relationship says we need to talk about this, but we can't have this. That's a little psychodynamic rather than person centered. When I say, we need to talk about this, but I think at Roger's best except the roots of the need, but certainly not offer any support for the behavior per se. August Baker: Excellent. Well, this has been a privilege to speak to you today Barry. This is a great book, Understanding and Enhancing Positive Regard in Psychotherapy: Carl Rogers and Beyond, Barry Farber, Jessica Suzuki, and Daisy Ort, 2022, American Psychological Association. Thanks for joining me. Barry A. Farber: My pleasure, August. August Baker: Thanks very much.