Analysis and Reflections on Sabina’s Course of Psychotherapy

Sabina used therapy effectively to draw on her personal resources to make great progress in almost all of her goals. Her involvement and active participation in therapy were consistently high. She came prepared each session to address issues of concern and did so in a courageous manner, even when the problems she dealt with were emotionally draining. Sabina consistently took responsibility for herself in therapy and in her daily life. She never complained about her fate or took the role of a victim in her family. Nor did she ever attribute her problems to racial prejudice, though she was certainly aware of its existence in her world. Instead, she engaged her will and determination to improve herself and her life. Her health problems, and especially her pain, were often debilitating and slowed her progress at times. Yet, despite the many difficulties she faced, she retained her positive attitude that she could deal with her challenges and thrive in her life.

I shared in Sabina’s pride in her enormous progress over the past 2 years. We often celebrated her progress over the course of our work together.

Looking through the lens of person-centered therapy, Sabina was certainly motivated to alleviate some major stressors in her life, particularly the ongoing strains and unfinished business with her mother and family. Regarding her mother, she strove to make sense of her mother’s leaving her at a very young age to have an adventurous life. The empathic exploration process we engaged in helped her understand that her mother was not invested in being a mother and that this was not a reflection on Sabina’s worth. Thus, Sabina came to see herself as worthy on her own merits despite her mother’s frequent criticism and limited interest or affirmation. Her self-regard was developed from a number of sources. Sabina was a highly regarded executive secretary who consistently received positive work evaluations. She also became a successful businesswoman by buying property in another state. A number of long-term friends valued Sabina’s steadfast friendship, kindness, generosity, and authenticity in speaking her mind. Thus, Sabina’s friends supported her in ways that her family did not. She was a good mother who continued to support and accept her son despite his problems with the law. Sabina also learned to be her own locus of evaluation. Independent of others, she was able to acknowledge her qualities and achievements while accepting her setbacks and limitations. She had a clear sense of herself and good self-esteem.

One of the primary ways Sabina mobilized herself to change was to set goals for herself. These ranged from a daily to-do list to projecting larger goals over the course of a year and beyond. While some of our work was focused on how goal achievement was impaired by Sabina, more often we worked toward her finding ways to stick to her goals. To her credit, she consistently returned to her goals and persisted in finding ways to achieve them.

As I look at my role in Sabina’s progress, a few things seem relevant. What I did that seemed to make a difference was consistently be fully present and listen intently and with genuine interest to all that concerned Sabina. As I listened to many of the tapes of our sessions, I realized that I allowed her to do a lot of the talking. I did so because Sabina used the sessions as a meditation on her life and how she was currently managing it, while also discovering necessary correctives. By responding empathically, I helped heighten, clarify, and explore her realities and to find her own ways to address issues and move forward. It is my perception that Sabina felt heard and understood by me and that she courageously took in and explored whatever we addressed. In terms of Sabina’s creating a more stable positive image, some contributions of mine come to mind. I believe that I served as a steadfast source of support, encouragement, and consistent optimism about her capacity to change. I think my genuine affection and liking for Sabina were evident to her, as was my acceptance for her as she was, something that reduced the conditions of worth she felt from her mother. In fact, I cannot recall ever feeling critical of her or even having moments of discord. This is extremely unusual in my experience, and I am somewhat amazed and puzzled by it. My sense of our therapy was that we just “clicked” early on and that the mutual liking and respect we experienced was always evident. I was myself and she was herself throughout our work. Sabina was the kind of person I could imagine as a good friend. I admired her as a mother and felt that she would make a fine partner in the right relationship. Although our relationship remained within appropriate professional boundaries, there was certainly an element of friendship in it. I always felt we were partners working together on her behalf.

There were additional aspects of our relationship that had a constructive effect on our therapeutic work. Whenever I met Sabina in the waiting room, she responded with a big smile and friendly greeting, no matter how troubled she may have been that day. She seemed genuinely happy to see me, and I was always happy to see her. Her friendly and positive presence with me elicited a similar response in me. An important point here is that the quality of relationship between therapist and client is not solely dependent on the therapist’s provision of empathy, congruence, and positive regard, a conceptualization that suggests that what therapists ideally do “for” clients is a unidirectional endeavor. Rather, therapist and client affect each other and, together, cocreate a relationship. My natural liking for Sabina was certainly enhanced by her liking for me. Laughter was a frequent part of our meetings, as were sober moments of engaging with serious issues and troublesome feelings. Sabina said that she appreciated my wisdom, understanding, and laughter. The fact that Sabina had difficulties with a number of men in her life, starting with her father, who let her down or abandoned her, was certainly not lost on me. It helped me understand how important it was to be a trustworthy and constant presence in her life, someone who did not let her down.

On occasion, Sabina made some spontaneous comments about my manner of relating to her. During one session, Sabina commented, “You keep it real” which I believe had two meanings: (a) I focused unhesitatingly on what was most relevant, however difficult; and (b) Sabina found me honest, direct, and trustworthy. I would add that we both “kept it real” by being transparent to each other.

Finally, I will share a few thoughts on my being a white therapist working with an African American woman. From the beginning, I never had the sense that our racial differences were an issue. I also had worked with many African American women over parenting issues when I was a child clinical psychologist for 8 years, something that familiarized me with black culture. However, a little nagging voice in the back of my head said I might be making an erroneous assumption. Some experts in the field of culture and race in therapy insist that race is always an issue. So I decided to ask if my being white was an issue in any way for her. Sabina said that my being a white male was not an issue for her. While we were, of course, aware of our racial differences, I related to Sabina the person much more than to Sabina the black person. I certainly paid attention to racial issues that arose (e.g., Sabina’s own frustration over finding a suitable black male partner), but our racial differences did not seem to play any major role in our work together. While such racial differences surely do come into play, I have come to believe that if, or to what degree, such issues matter, the client is the best guide about how such issues might be addressed.

Evaluation

Rogers was a pioneer in initiating and publishing research studies on the process and effectiveness of person-centered psychotherapy beginning in the early 1940s. This research tradition has continued and today, about 70 years later, there is a substantial body of research supporting the effectiveness of person-centered psychotherapy with a wide range of clients and problems of all age groups. In 1984, C. H. Patterson conducted a “review of reviews” of the extensive research on the effectiveness of the core conditions of person-centered therapy. Patterson concluded:

Considering the obstacles to research on the relationship between therapist variables and therapy outcomes, the magnitude of the evidence is nothing short of amazing. There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness is incontrovertible. (1984, p. 435)

In a recent and comprehensive review of research in person-centered therapy, Bozarth, Zimring, and Tausch (2002) summarized their findings as follows:

In short, psychotherapy outcome research supports the major tenets of CCT [client-centered therapy]. The therapeutic relationship and the client’s resources are the crux of successful therapy and the foundation of CCT. It is also clear that Rogers’ specific hypothesis of the necessary and sufficient conditions . . . has received much more empirical support than some of the equivocal reviews of the middle 1970s imply. Research has supported the theory that a congruent therapist’s experience of empathic understanding of the client’s frame of reference and experience of unconditional positive regard are related to positive outcome. (p. 179)

RESEARCH SUPPORTING CORE CONDITIONS

Research on the relationship between the therapist conditions of empathy, unconditional positive regard, and congruence and client outcome is generally positive. The evidence for each therapist condition is summarized below.