Question: “What is unconditional positive regard and how we can apply it effectively to clients?”
Recently, my supervisor watched a video recording of my session with a client and she said that I was not “showing unconditional positive regard”. When I asked her to elaborate, she said that I was “confronting the client” instead of “being on the same side”. The parts she referred to were moments when I’d say things like, “And would you say that behaviour helps you? What might be the consequences further along the line?”
I have good rapport with this client and, in another moment, he tried to repeat for the nth time that his avoidant behaviours (e.g. playing video games for hours) weren’t a problem at all. I replied, “If you remember back to our first session, when I asked why you were here, you said that your game playing and other hobbies were affecting your relationship. And here you are saying it’s not a problem…can you help me to understand what makes you now say it’s not a problem?”
I am on the same side as my client – I’m trying to help him make sense of his behaviours and his apparent confusion about whether they’re a problem or not. Sometimes, I get the feeling that people take “unconditional positive regard” to mean “always be nice no matter what”, but I’d say to be a compassionate therapist you have to confront the client’s defences and contradictions at times to reflect to them their own words and thought processes.
I accept that sometimes I can be direct in my confrontation, and I always try to let the client know that it’s in order to help them; I’m not judging them, although I appreciate it could come across that way. I do what I can to clarify if I see the client is affected by my questions, and my confronting is selective.
My supervisor is quite helpful (I’m an intern trainee counsellor), but I think that some people use unconditional positive regard as an automatic phrase rather than really understanding what it means.
As I understand it, positive regard is toward the client’s potential for growth, that regardless of their issue, the issues don’t define who they are and they have the capability to function and live well with the help of therapy.
With that in mind, I believe compassionate confrontation is important in therapy, otherwise it feels like I’m turning the client into a victim and removing their own sense of agency.
It would be helpful to know your thoughts on unconditional positive regard and how we can apply it effectively to clients.
Response from Dr. Chua:
That’s a great question. I agree that people often misunderstand what unconditional positive regard means. Let me just quote what Rogers says about unconditional positive regard to make sure we are both on the same page.
“The second attitude of importance in creating a climate of change is acceptance, or caring or prizing – what I have called “unconditional positive regard”. When the therapist is experiencing a positive, acceptant attitude toward whatever the client is at that moment, therapeutic movement or change is more likely to occur.
“The therapist is willing for the client to be whatever immediate feeling is going on – confusion, resentment, fear, anger, courage, love or pride. Such caring on the part of the therapist is non-possessive. The therapist prizes the client in a total rather than a conditional way.” (Carl Rogers, A Way of Being)
It is also important to remember that this is only one of the three growth promoting conditions – the other being the therapist’s genuineness or congruence, and the therapist’s empathic understanding. Unconditional positive regard alone is insufficient and cannot truly be present without congruence and empathic understanding.
Most modern day therapies have moved away from a pure empathic/reflective approach to a collaborative process that guides the client forward toward their treatment goals. However, even in Cognitive Behavioural Therapy, confrontation is not encouraged. Rather the therapist collaborates with the client to explore the issue at hand through Socratic questioning.
So, let’s look at the interaction you had with your client:
‘He tried to repeat for the nth time that his avoidant behaviours (e.g. playing video games for hours) weren’t a problem at all. I replied, “If you remember back to our first session, when I asked why you were here, you said that your game playing and other hobbies were affecting your relationship. And here you are saying it’s not a problem…can you help me to understand what makes you now say it’s not a problem?”‘
- What modality are you using? You need a clear understanding of not just what you are doing and why, but also an understanding of your client’s problems in living. Your understanding of your client’s problems will shape what you do in therapy.
- What is the treatment goal? When you asked your client why he was here, he said “game playing and other hobbies were affecting his relationships”. This is an identification of a problem but not necessarily the goal of therapy. Does your client want to stop game playing? Does your client want to improve his relationships? What is the focus of your intervention? Why are you trying to “to help him make sense of his behaviours and his apparent confusion about whether they’re a problem or not.”?
It doesn’t sound like your client is confused – he clearly said and repeated for the nth time that they weren’t a problem. What does your client actually want to work on? Does your client agree with the way you are going about it? Remember, collaboration is key. Check in with your client about how they’re experiencing the process as you go along…especially if you’re feeling stuck or unsure as the therapist. This will help you both to reorient yourselves to the client’s needs in therapy.
- Are the growth-promoting conditions present? Your client says that game playing is no longer a problem. Maybe he is right, and it is no longer a problem, or maybe he is trying to tell you to ease up. I don’t know why he said that, but it appears that you don’t accept what he says. I wonder why not.
So, in the spirit of Rogers’, are you empathising with him? Are you congruent with what you are feeling? And are you prizing and valuing your client even if he is avoidant?
What do you feel when your client says game playing is no longer a problem? Are you making yourself transparent to the client?
What does your client mean by that statement? What is he experiencing? Are you experiencing a positive and accepting attitude toward however your client is at that moment?
Positive regard is not toward the client’s potential for growth. Positive regard is you prizing your client at this moment, who they are now, not who they might be in the future.
We build our client’s agency when we accept what our clients are saying and feeling and collaborate with them to achieve their goals. The conditions of growth – unconditional positive regard, congruence, and empathic understanding – drives our therapeutic strategies forward. They are important regardless of the modality you are using, as they address the person we are and how we relate to our clients.
Note: I think very few people are really doing “pure” Rogerian person centered therapy. I have found it very useful to read the transcripts of his sessions and to watch his videos to understand how he conducts therapy. You can find these recordings and the transcripts online.
There is also a great article by Lietaer & Gundrum (2018). They analysed Rogers’ responses in therapy and found that the majority of his responses were responses of empathic understanding – “restatement of narrative aspects, reflection of expressed feelings, reflection of underlying feelings and checking questions”. He used “confrontation” sparingly – only about 1% of the time.
Lietaer, G., & Gundrum, M. (2018). His master’s voice: Carl Rogers’ verbal response modes in therapy and demonstration sessions throughout his career. A quantitative analysis and some qualitative-clinical comments. Person-Centered & Experiential Psychotherapies, 17(4), 275-333.)
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