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DIAGNÓSTICOS E ABORDAGEM CENTRADA NA PESSOA
DIAGNOSIS AND PERSON CENTERED APPROACH
João Hipólito1, Odete Nunes1, Rute Brites1, Ana Jarmela2
PSIQUE • EISSN 21834806 • VOLUME XVIII • ISSUE FASCÍCULO 2
1ST JULY JULHO 31ST DECEMBER DEZEMBRO 2022 • PP. 4349
DOI: https://doi.org/10.26619/2183-4806.XVIII.2.1
Submited on 2.02.22 Submetido a 2.02.22
Acceptted on 4.05.22 Aceite a 4.05.22
Abstract
It has been widely held that Carl Rogers was strongly negative towards diagnoses as
useless and even harmful. However, during the analysis of his work, it appears that he used,
without prejudice, the traditional diagnoses of psychopathology, as can be seen in works such
as Psychotherapy and Personality Change (1954), Psychotherapy and its Impact (1967) and On
Personal Power (1977). In our opinion, your attitude would be based on a pragmatic approach
to communication. However, with the paradigm shift assumed in December 1940, from the
biomedical to the “new therapies”, C. Rogers started to use, without expressly mentioning
it, a new diagnostic device. This “tool”, based on the six necessary and sufficient conditions
for therapeutic change, constitutes a relational “means of diagnosis” and, in our perspective,
consistent with the attitude of trust in the client’s capacity for self-organization, a fundamental
element for the development of the therapeutic process. In this sense, the present article aims to
describe C. Rogers’ “journey” and his consistency of thought regarding the diagnostic process
and its use.
Keywords: ACP; diagnoses; biomedical model; self-organizing model; therapeutic response.
Resumo
Tem sido largamente disseminada a ideia de que Carl Rogers possuía uma posição franca-
mente negativa face à elaboração de diagnósticos, considerando-os inúteis e, mesmo, nocivos.
Contudo, no decorrer da análise do seu trabalho, constata-se que utilizava, sem preconceitos, os
diagnósticos tradicionais da psicopatologia, como é possível verificar em obras como Psychothe-
rapy and Personality Change (1954), Psychotherapy and its Impact (1967) e On Personal Power (1977).
Em nossa opinião, a sua atitude basear-se-ia numa abordagem pragmática da comunicação. No
entanto, com a mudança de paradigma assumida em dezembro de 1940, do biomédico para o
1 Universidade Autónoma de Lisboa, Lisboa, Portugal. Centro de Investigação em Psicologia (CIP/UAL)
2 Universidade Autónoma de Lisboa, Lisboa, Portugal
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João Hipólito, Odete Nunes, Rute Brites, Ana Jarmela
“das novas terapias”, C. Rogers passou a utilizar, sem expressamente o mencionar, um novo apa-
relho diagnóstico. Esta “ferramenta”, baseada nas seis condições necessárias e suficientes para
a mudança terapêutica, constitui um “meio de diagnóstico” relacional e, na nossa perspetiva,
coerente com a atitude de confiança na capacidade de auto-organização do cliente, elemento
fundamental para o desenvolvimento do processo terapêutico. Neste sentido, o presente artigo
tem como objetivo descrever o “percurso” de C. Rogers e a consistência do seu pensamento no
que se refere ao processo de diagnóstico e sua utilização.
Palavras-chave: ACP; diagnósticos; modelo biomédico; modelo auto-organizativo; resposta terapêu-
tica.
In the theoretical and clinical world of Client Centered Therapy / Person Centered Approach
there seems to be a common “belief” that Rogers was deeply against the use of diagnoses in
therapy. This belief is probably based on texts by the author such as: “I’m forced to the conclusion
that such diagnostic knowledge is not essential to psychotherapy. .... a colossal waste of time”
(Rogers, 1957, p. 95-103).
As mentioned in the Journal of Humanistic Psychology (1986c), Carl Rogers evolved and
made his thinking more complex, in order to pass “from a young ‘diagnostic-prescriptive’ clinical
psychologist to one who had come to trust the great potential residing within the individual
for self-understanding and self-direction” (Rogers, 1990). This article presents a chronology of
Rogers’ perspective on the diagnostic process.
In Rogers first published book, Measuring Personality Adjustment in Children Nine to Thirteen
Years of Age (1931/1972) he developed an instrument, referred yet nowadays (Burchinal et al.,
1958; Westbury, 2011).
This book was followed on 1939 by The Clinical Treatment of the Problem Child, being the
diagnostic quite present as a previous condition for treatment project, framing it on a quite
traditional biomedical paradigm. In his next book, Counseling and Psychotherapy (1942), Rogers
described the client’s journey in five stages, one of which, the fourth, involves “positive planning
and actions” suggesting a prior diagnosis. The path is described thus: (1) The client comes to help
(2); He expresses emotionalized attitudes freely (3); This leads to the development of insights (4;
These results in positive planning and actions (5) The client terminates the contact. Regarding
“Insight”, Rogers referred that, when the client develops insight into his personality, there is a
reorganization of old facts that occurs (Rogers & Wallen, 1946, p. 53).
It should be noted that the biomedical paradigm is based on the diagnosis, which is expected
to be etiological, allowing a successful specific treatment. Psychological diagnostic tools, like all
other diagnostic tools used within the biomedical model, must more or less inevitably contribute
to achieving this goal.
In the conference entitled Newer Concepts in Psychotherapy, held on December 11st, 1940
at the University of Minnesota, Rogers introduced a new paradigm, shifting from a biomedical
model to the first approach to positive psychology embodied in a holistic approach centered on
self-organization and self-reliance of the organism. In his speech, the following is mentioned: (1)
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Diagnósticos e Abordagem Centrada na Pessoa
“(…) It relies much more heavily on the individual drive toward growth, health and adjustment;
(2) “(…), places greater stress upon the emotional elements, than upon the intellectual aspects
(…)”; (3) “(…) places greater stress upon the immediate situation than upon the individual’s past”;
4 “(…) the therapeutic contact is itself a growth experience” (Rogers, 1942, 42-44)
Rogers was surprised by the reactions his speech provoked. He later regarded this conference
as the birth of Client-Centered Therapy (Kirshenbaum, 2007, p. 109).
In his book entitled Counselling and Psychotherapy (1942), a basic hypothesis on Counselling
was presented: “Effective counselling consists of a definitely structured permissive relationship
which allows the client to gain an understanding of himself to a degree which enables him to
take positive steps in the light of his new orientation” (Rogers, 1942, p. 18). Posteriorly, Rogers
presented the following provisional indication criteria for carrying out a therapeutic process: (1)
The individual is under a degree of tension (…); (2) The individual has some capacity to cope with
life. (…); ( 3) There is an opportunity for the individual to express his conflicting tensions in (…);
(4) He is able to express these tensions and conflicts either verbally or (…); (5) He is reasonably
independent, either emotionally or spatially, of close family control; (6) He is reasonably free from
excessive instabilities, particularly of an organic nature; (7) He possesses adequate intelligence
to cope with his life situation, (…); (8 ) He is of suitable age – old enough (…), young enough (…)
roughly from ten to sixty. (1942, p. 76-77).
Rogers (1942) also mentioned the conditions of non-applicability of the Client-Centered
Therapy model: “The component factors of the individual’s adjustment situation are so adverse
that (…); (2) The individual is inaccessible to counselling (…); (3) Effective environmental treatment
is simpler and more efficient (…); (4) The individual is too young or too old, or too dull, or too
instable (…)” (p. 78-79).
From a broader theoretical context, Rogers, in 1957, presented a “second diagnostic system”,
the Necessary and Sufficient Conditions of Therapeutic Personality Change - six conditions are
postulated as necessary and sufficient conditions for the initiation of a process of constructive
personality change:
“ (1) Two persons are in psychological contact; (2) The first, whom we shall term the client,
is in a state of incongruence, being vulnerable or anxious; (3) The second person, whom
we shall term the therapist, is congruent or integrated in the relationship; (4) The thera-
pist experiences unconditional positive regard for the client; (5) The therapist experien-
ces an empathic understanding of the client’s internal frame of reference and endeavors
to communicate this experience to the client; (6)The communication to the client of the
therapist’s empathic understanding and unconditional positive regard is to a minimal
degree achieved” (p. 95-103).
According to this new conception, “diagnostic knowledge is not essential for psychotherapy.
However, in a footnote, Rogers (1957) states: “there is no intent here to maintain that diagnosis
evaluations are useless. We have ourselves made heavy use of such methods in our research
studies of change in personality. It is usefulness as a precondition to psychotherapy which is
questioned” (Kirschenbaum & Henderson, 1990, p. 232).
Georges Engels (1977) also showed the insufficiency of this biomedical model and proposed “a
new paradigm”, not really a paradigm shift but an enrichment of the old model who become, the
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João Hipólito, Odete Nunes, Rute Brites, Ana Jarmela
“Bio psycho social” model. Later Engels’ model got some “improvements” to become as including
as Bio psycho socio anthropological and noetic. However, a deeper analysis of the model or of his
utilization shows its strong main biomedical roots.
Some authors, as Lisbeth Sommerbeck, followed Rogers on the benefits of using
psychopathology diagnosis, as a way of keep communication or understand other professionals
(2003). As already mentioned, psychiatric diagnosis is not a problem in Client-Centred Therapy
(...) However, both because of clients’ questions about their diagnosis and because of the language
of the medical model and psychiatric diagnosis which is dominant in the psychiatric hospital
environment, the client-centred therapist must be able to communicate in this language with
other staff and professionals when integrated in this professional culture. The therapist should
thus be able to decode the perspective of the medical model but also from the client-centred
perspective.
It should be noted that in the work Psychotherapy and Personality Change, Rogers mentioned
“some of their clients’ diagnosis: neurotics, borderline, normal (...)”, “more acute schizophrenic,
more chronic schizophrenics, normal and neurotics (...)” (Rogers & Dymond, 1954, pp. 41, 67).
In the book On Personal Power, Rogers also referred: “There is one perspective (...) which I,
and most other humanistic psychologists, are reluctant to admit. This is the possibility that there
was a chemical factor (...) His positive responses to a correct lithium dosage occurred twice –
once in his depression and once when he was maniac – and forces me to consider this possibility”
(Rogers, 1977/ 1986a, p. 232).
In fact, these quotations show that we are dealing with two different paradigms:
1. An essential biomedical, needing diagnostics to prescribe a treatment, even within
psychodynamic orientated models, like the example of the “The Hamburg short psychotherapy
comparison experiment” (Kimm et al., 1981; Meyer, 1981), where it was possible to find a well-
structured study of brief psychoanalytic orientated psychotherapy using Malan’s focus theory
to support his therapeutic approach within a biomedical model. The study compares a sample
of patients getting this treatment on a base of a biomedical diagnostic psychoanalytically
orientated using Malan’s brief focus theory to support his therapeutic approach, with another
sample of patients getting time-limited therapy by Client-centered therapists, ignoring
completely the psychoanalytical biomedical criteria for this treatment’s choice, ignoring the
basic psychoanalytical etiological hypotheses and using another therapeutic paradigm.
2. A holistic new paradigm offering to all the adequate clients the same therapeutic approach:
Client-centered Therapy/Nondirective Therapy.
This new paradigm has, however, his own diagnostic system, which is based on the six
necessary and sufficient conditions of therapeutic personality change proposed and discussed
by Rogers: Either all the Six Conditions are present or not. If not, client-centered therapy it’s not
possible3.
3 What can we do to make those missing available?
For example, Garry Prouty (1994) worked mainly with the first condition, but the same principles can be applied
to all the remaining conditions. For Prouty (1994), “Pre-Therapy, in broad terms, is presented as the development
of the psychological functions necessary for psychotherapy: reality, affective, and communicative contact.
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In fact, several professionals recognize the importance of the six conditions. However, some
of them claim that they are necessary but not sufficient; for others, they may be neither necessary
nor sufficient, thus departing from Rogers’ position.
The concept of the Person-Centered Approach appears as the philosophy behind all Carl
Rogers interventions and the “core conditions” as
growth promoting climate, whether we are speaking of the relationship between thera-
pist and client, parent and child, leader and group, teacher and student, or administrator
and staff. The conditions apply, in fact, to any situation in which the development of the
person is a goal (Rogers, 1986b, p. 9).
The “core conditions” are congruence, unconditional positive regard, and empathic
understanding. Later, Rogers added a fourth condition, presence (Brodley, 2011, p.140).
Barbara Brodley (2011) has demonstrated that Carl Rogers therapeutic practice and
intervention remained quite stable and similar along all his life, no matters the evolution of his
thinking, or as we would prefer, the unfolding of his reflections. She pretends that if Rogers’
position on diagnostic and psychometrics usefulness changed within his lifespan, his practice
remained constant.
Barbara Brodley studied 34 Rogers’ interviews from 1940 to 1986. Although it was possible
to find
evidence of a radical shift from a theoretical to a functional nondirectivity and empathic
understanding (…) between (circa) 1941 and (circa) 1945; there was possible to note that
between 1944 and 1986 there is evidence of a development (…) towards a more personal
expression of himself in his interaction with his clients (…). They are also, almost always,
consistent with Rogers’ theoretical and personal views that the only goals, when working
with a client, are the goals for oneself – to be real, to be acceptant and to be empathic
(2011, p.326).
In a personal communication, Brodley expressed her opinion that the stability in the Rogers
practice along those 45 years, was constant together with his theoretical evolution.
Conclusion
In the new paradigm, the diagnostic system is based on the Six Necessary and Sufficient
Conditions of Therapeutic Personality Change. According to our reflection and practice and
following Rogers’s proposal, we consider that these six necessary and sufficient conditions for
therapeutic personality change can be used as a relational diagnostic system (Hipólito et al., 2014).
This requirement points out the importance of other approaches when one of these conditions is
not present, either to promote them or to find other applicable therapeutic proposals (Brites, et
al., 2016).
Once the six conditions are present, it does not matter which psychiatric or psychological
“label” or diagnosis was used, or which classification system was adopted, ICD-11 (World
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João Hipólito, Odete Nunes, Rute Brites, Ana Jarmela
Health Organization, 2022) or DSM-V (American Psychiatric Association, 2014). The indication
for psychotherapy is present and the client can improve to become more and more a “fully
functioning person” (Rogers, 1963, p.17).
Despite some psychiatrists may consider psychotherapy not indicated for certain psychiatric
diagnoses, even considering the non-use of neuroleptics or the exclusive use of psychotherapy as
a “bad practice”, research shows that the client can find a positive evolution, either associating
psychotherapy or community therapy.
Soteria’s programs showed it, against medical opposition and preconceived ideas. We
developed this approach in a 2007’s paper, New Versions of Schizophrenia: psychotherapeutic
advances (Hipólito, 2007).
As Sommerbeck (2003) mentioned, the psychiatric diagnostic might be useful, not only for
research proposes, epidemical studies, or to share with other non-Client-centered clinicians, but
to help to relief suffering in clients where the six condition are not present, or until they became
present.
We can agree with Rogers (1951/ 2003) that: “…client-centered therapy has been at the end of
the continuum in stating, as its point of view, that psychological diagnosis as usually understood
is unnecessary for psychotherapy and may actually be a detriment to the therapeutic process”.
(p.220).
We can also agree with him in his statement:
The therapist must lay aside his preoccupation with diagnosis and his diagnostic shrewd-
ness, must discard his tendency to make professional evaluations, must cease his endea-
vors to formulate an accurate prognosis, must give up the temptation subtly to guide the
individual, and must concentrate on one purpose only; that of providing deep unders-
tanding and acceptance of the attitudes consciously held at this moment by the client as
he explores step by step into the dangerous areas which he has been denying to cons-
ciousness. Diagnostic knowledge and skill are not necessary for good therapy (Rogers,
1946, p. 421).
In the same way we have to coexist with Systemic and Cartesian paradigms, we will have to
cope with the two paradigms in Therapy: the old Biomedical and the “New therapies “of Rogers’
holistic Client Centered Therapy. In any case we should be aware of the need of being congruent
in our therapeutic approach and most of all in every circumstance being congruent with this
“new way of being”, the Person-Centered Approach.
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