CIUDADANÍA INTELIGENTE

This is de®ned by Swildens (2004, p. 16) as `the diversi®cation of the client- centred attitude and its implementation on behalf of clients with actual or supposed dif®culties in receiving therapeutic interventions in one or more phases of therapy'. There is currently a lively debate within the person- centred and experiential therapeutic world in which different `tribes' take different stances on this (see Takens & Lietaer, 2004). The debate, in part, rests on therapists' view of diagnosis.

Rogers (1951) was opposed to the use of diagnostic labels applied to psychological dynamics, viewing it as unnecessary, and detrimental to the therapeutic process. Rogers' objection to diagnosis was twofold. First, it places the locus of evaluation in the hands of experts which, he argues, leads to a dependency in clients (1951, p. 224): `there is a degree of loss of personhood as the individual acquires the belief that only the expert can accurately evaluate him, and that therefore the measure of his personal worth lies in the hands of another'. Second, diagnosis, for Rogers and others, has undesirable social and philosophical implications, such as the diagnostician having control over the client or patient, control which, ultimately, may take the form of assessment, sectioning under mental health (illness) legislation, and con®nement.

A further note, which may be an objection for some, and a relief for others, is that diagnosis changes over time. A study of the history of diagnostic categories reveals considerable change over the past 100 years. Perhaps the most infamous example was the removal of homosexuality from the APA's (1968) DSM II in the publication of its third edition (DSM III ) in 1980. In a brief review of the phenomenon of hysterical syndromes, Swildens (2003, p. 8) comments about symptoms and conditions which have disappeared and others which have taken their place: `Perhaps such fashionable renaming is not so much an expression of a shift in psycho- pathology as a manifestation of the dominance of a different school of therapy.' It seems that our view of what is `neurotic' is more likely to change according to changing social mores than what we refer to as `psy- chotic', which seems more constant across time and cultures. Some of our de®nitions of what is neurotic depend on what is socially sanctioned or desirable. There is, for instance, current concern about the extent to which the American health insurance industry shapes the categorisation of disorders in the APA's DSM. We think this is particularly important for person-centred therapists who, in discussions with practitioners from other theoretical orientations and other professions, as well as with clients, may take a less popular but longer view of the usefulness of particular diagnostic categorisations of symptoms.

Others since have followed and elaborated Rogers' lines of thinking. On the basis that the primary purpose of diagnosis is to determine treatment,

Shlien (1989) argues that, since client-centred therapy has only one `treat- ment' for all clients, i.e. working in the context of the necessary and suf®cient therapeutic conditions, then diagnosis is irrelevant. This has led to some criticism of person-centred therapy as advancing a kind of therapeutic uniformity. Rogers (1951, pp. 223±4) advances a number of propositional statements regarding diagnosis, concluding that:

Therapy is basically the experiencing of the inadequacies in old ways of perceiving, the experiencing of new and more accurate perceptions, and the recognition of signi®cant relationships between perceptions.

In a very meaningful and accurate sense, therapy is diagnosis, and this diagnosis is a process which goes on in the experience of the client, rather than the intellect of the clinician.

In our view this is both a more moderate and more radical proposition than the complete rejection of diagnosis. It is more moderate in that it retains the concept of diagnosis, a position which, we believe, has led to the recent elaboration of and debate about differential process. It is more radical in that it clearly places the locus of evaluation and control in the hands of the client. There is, for instance, a world and a paradigm of difference between the statements `The doctor sent me. I'm depressed.' and `I'm mad and I'm angry.' For Holland (1988) these statements represent a shift from a functionalist to an interpretative paradigm.

In the context of the dominance of the medical/psychiatric model this person-centred attitude to diagnosis is counter-cultural. It can place person- centred therapists outside of, or at least viewed with some suspicion by, institutions such as the National Health Service in the UK. In response, Tudor and Merry (2002) summarise three approaches to diagnosis taken by person-centred practitioners:

1 To eschew diagnosis completely ± as represented by Shlien (1989). 2 To seek to understand other systems (medicine, psychology and other

psychotherapeutic approaches) and their approaches to psychopathol- ogy, diagnosis, assessment and treatment, and to translate them into person-centred language, theory and concepts ± for example, Speierer (1990) and Joseph and Worsley (2005).

3 To develop a person-centred/experiential approach:

i. To `illness', `mental illness' and `disorder', thus, illness as incon- gruence (Biermann-Ratjen, 1998; Speierer, 1996); person-centred theory and mental illness (Wilkins, 2005).

ii. To psychodiagnosis and assessment (Fischer, 1989; Wilkins & Gill, 2003).

iii. To speci®c `conditions' such as borderline personality disorder (Bohart, 1990); fragile and dissociated process (Warner, 1991, 1998); neurosis (Lambers, 1994); depression (Catterall, 2005; Rowland, 2002; Schneider & Stiles, 1995); schizophrenic thought disorder (Warner, 2002); narcissistic defence (Swildens, 2004); psychotic functioning (Van Werde, 2005); anti-social personality disorder (McCulloch, 2005); autism and Asperger's syndrome (Knibbs & Moran, 2005); post-traumatic stress (Joseph, 2005).

It is in elaborating these developments that differences have emerged between what is characterised as a more classical person-centred therapy and experiential therapy.

Proponents of process differentiation argue, as the term suggests, that it is useful to differentiate a client's process. As we see (above), Swildens writes about `the diversi®cation of the client-centred attitude'. This implies that, depending on the client's process (depressive, schizophrenic, border- line, narcissistic, and so on), the therapist offers a diversi®ed and differ- ential response. If such responses are framed in terms of more empathy for this client, more congruence with regard to another, clearer boundaries for one, fewer for another, then this would be clearly at odds with the prin- ciples of person-centred therapy and, speci®cally, Rogers' therapeutic attitudes or conditions (see Chapter 7), and the process of therapy (see Chapter 8). Acknowledging the advances that person-centred therapy has made with regard to understanding client processes, and citing the work of Prouty (1994) and Warner (2000), Mearns (2004, p. 98) argues: `It is not that these client processes demand particular therapeutic protocols additional to the principles of person-centred working; rather, it is that these processes create particularly demanding relationships in terms of communication, engagement and trust.'

We think that the answer to what at times appears to be an impasse between two polarised positions is summarised by three propositions: 1 That the therapeutic relationship is a signi®cant curative factor in

psychotherapy. As Schmid (2004, p. 41) puts it: `Since it is the relationship that facilitates the process of personalization, differ- entiated relationships are needed: each person-to-person relationship is different, otherwise it would not be a personal relationship.'

2 That the most signi®cant experience of differentiation is the client's. In other words, clients experience and, in various ways, construe their experience: one person is constantly suspicious of her neighbours, another isolates himself, a third experiences acute discomfort in close relationships, a fourth shows disregard for others, and so on. As therapists we may have a number of ways of conceptualising and understanding different differentiations. The ultimate test of these

theories, however, is whether they help us to be empathic, and whether they help the client `diagnose' herself (see Rogers, 1951). Of course our empathy for different clients is different ± because they're different, and because each therapeutic relationship is different. This perspective addresses the `uniformity myth' that person-centred therapy and therapists are the same. As Schmid (2004, p. 40) puts it, `the therapeutic answer is: not uniform but unique'.

3 That forms of therapy, such as pre-therapy, or therapeutic techniques (if used at all) are best conceptualised as forms of empathy, whether empathic understanding, empathic attunement, empathic responding, accurate empathy (Truax & Carkhuff, 1967), idiosyncratic empathy (Bozarth, 1984), or different levels (Truax & Carkhuff, 1967) or kinds of empathy (Neville, 1996). This reconceptualisation places such therapy with various forms of differentiated process, i.e. fragile (Warner, 1991), dissociated (Warner, 1998), psychotic, depressed (Rowland, 2002), and disconnected (Mearns & Cooper, 2005), at the heart of the person-centred therapeutic endeavour and process, rather than before it.