Week 7: Cognitive, Behavioral, and Cognitive-Behavioral Therapy 4 Week 7: Cognitive, Behavioral, and Cognitive-Behavioral Therapy What is CBT?: We will look today at Cognitive Behavioral Therapy (CBT), one of the most widely used and empirically supported forms of psychotherapy. CBT is based on the idea that thoughts, emotions, behaviors, and physiological reactions are interconnected. Psychological problems are maintained by maladaptive thinking patterns and dysfunctional behaviors, and treatment aims to identify and modify these patterns in order to reduce distress and improve functioning. Week 7 The summary of WEEK helps you quickly understand the core of Cognitive, Behavioral, and Cognitive-Behavioral Therapy and apply it to exam questions. You will learn: • What is CBT? • Core principles of CBT • The CBT model • Cognitive techniques • Behavioral techniques • The therapeutic alliance in CBT • Corrective Experiences • Effectiveness of CBT • Comparison with other therapeutic approaches This material accounts for approximately 14% of the exam. Week 7: Cognitive, Behavioral, and Cognitive-Behavioral Therapy 5 Core Principles of CBT CBT is grounded in learning theories and cognitive theory. According to CBT, individuals develop beliefs and assumptions about themselves, others, and the world through experiences. These beliefs influence how situations are interpreted, which then affects emotions and behaviors. Dysfunctional interpretations can therefore contribute to psychological distress. A major goal of CBT is helping clients recognize automatic thoughts and maladaptive beliefs that maintain their problems. Therapists work collaboratively with clients to test these thoughts and develop more adaptive ways of thinking and behaving. Here are the essentials of CBT: • CBT is based on learning theories. • The therapeutic alliance is a precondition for effective CBT techniques. • CBT uses cognitive and behavioral techniques. • Therapy aims to provide corrective experiences. The CBT Model The CBT model assumes that situations themselves do not directly cause emotional reactions. Instead, the interpretation of a situation determines emotional and behavioral responses. CBT therefore focuses on identifying: • automatic thoughts, • underlying assumptions, • core beliefs, • and behavioral patterns. Therapists help clients understand how these processes interact and maintain psychological difficulties. Cognitive Techniques CBT uses various cognitive techniques to challenge dysfunctional thinking patterns. One important method is cognitive restructuring, where clients learn to identify distorted thoughts and replace them with more realistic and balanced interpretations. Tip! In CBT, thoughts are not seen as facts, but as interpretations that can be questioned and changed. A key therapeutic skill is helping clients become aware of automatic thoughts and evaluate whether they are realistic, helpful, or distorted. This process encourages cognitive flexibility and can reduce emotional distress over time. Examples: For example, two individuals may experience the same event but react very differently depending on their beliefs and thoughts. Week 7: Cognitive, Behavioral, and Cognitive-Behavioral Therapy 6 Therapists often use questioning techniques, evidence gathering, and behavioral experiments to evaluate the accuracy of beliefs. Behavioral Techniques Behavioral techniques are another central aspect of CBT. Since behaviors can maintain psychological problems, changing behavior can lead to emotional and cognitive change. Common behavioral interventions include: • exposure exercises, • behavioral activation, • relaxation training, • skills training, • and homework assignments. Homework is particularly important in CBT because therapy is viewed as an active process that continues outside sessions. Clients practice new skills and apply them to everyday life situations. The Therapeutic Alliance in CBT Although CBT is often associated with structured techniques, there is strong importance placed on the therapeutic relationship. Research consistently shows that the alliance between therapist and client is one of the strongest predictors of successful therapy outcomes. In CBT, the alliance is seen as: • collaborative, • goal-oriented, • and supportive. Tip! Cognitive distortions are common and occur in everyone to some extent, especially during stress or emotional distress. In CBT, the goal is not to eliminate negative thoughts completely, but to help clients recognize unhelpful thinking patterns and develop more balanced and evidence-based interpretations of situations. Tip! Behavioral techniques in CBT are based on the idea that change often happens through action. Even small behavioral changes, such as gradually facing feared situations or increasing pleasant activities, can positively influence emotions and thoughts. Homework assignments are therefore an essential part of CBT, as they help clients apply therapeutic strategies in real-life situations and strengthen long-term change. Examples: Examples of cognitive distortions include: • catastrophizing, • overgeneralization, • black-and-white thinking, • and selective attention to negative information Week 7: Cognitive, Behavioral, and Cognitive-Behavioral Therapy 7 The therapist and client work together as a team to understand problems and develop solutions. CBT techniques are only effective when a good alliance is present. Corrective Experiences An important concept discussed during the lecture was the idea of corrective experiences. CBT aims to create new experiences that contradict maladaptive beliefs. These experiences help weaken dysfunctional beliefs and strengthen healthier patterns of thinking and behavior. Effectiveness of CBT So how effective exactly is CBT? We will review research evidence supporting its efficacy. CBT is considered one of the most evidence-based psychotherapies and has been shown to be effective for a wide range of disorders, including: • depression, • anxiety disorders, • obsessive-compulsive disorder, • PTSD, • eating disorders, • and many others. Meta-analyses and NICE guidelines were mentioned as important sources supporting CBT effectiveness. Comparison With Other Therapeutic Approaches CBT can be compared to several other therapeutic orientations to further examine its effectiveness. • Psychodynamic Therapy: Psychodynamic therapy focuses on unconscious affect, relational patterns, and establishing epistemic trust. The therapist is viewed as an instrument of change, and therapy emphasizes exploration of unconscious processes. Tip! The strong research support for CBT is one reason why it is widely recommended in clinical guidelines around the world. However, the effectiveness of CBT can still vary depending on factors such as client motivation, the therapeutic alliance, and the suitability of the intervention for the individual’s specific needs and circumstances. Tip! A strong therapeutic alliance is considered one of the most important factors in successful psychotherapy, regardless of the therapeutic approach. In CBT, collaboration and trust help clients feel safe enough to explore difficult thoughts, emotions, and behaviors, making therapeutic techniques more effective and meaningful. Examples: For example, a socially anxious client who expects rejection may discover through behavioral experiments that social interactions can be safe and manageable. Week 7: Cognitive, Behavioral, and Cognitive-Behavioral Therapy 8 • Humanistic Therapy: Humanistic therapy emphasizes that the client is the expert on their own experience. The therapist acts as a facilitator and focuses on emotional experiencing and personal growth. • Family Therapy: Family therapy views the relationship or family system as the client. It emphasizes multiple perspectives, shared meanings, and systemic interactions between family members. CBT Compared to Other Approaches Compared to these approaches, CBT is generally: • more structured, • more goal-oriented, • and more focused on present thoughts and behaviors. However, modern psychotherapy increasingly integrates relational and interpersonal factors across orientations. Conclusion CBT is a structured, collaborative, and evidence-based therapy approach that helps individuals identify and change maladaptive thoughts and behaviors. CBT combines cognitive and behavioral interventions with a strong therapeutic alliance in order to promote meaningful psychological change. Although CBT has distinct theoretical foundations and techniques, successful psychotherapy in general depends heavily on relational factors, client characteristics, and the therapeutic context

Chapter 13: Research on Humanistic-Experiential Psychotherapies: Updated Review Introduction Humanistic-experiential psychotherapies (HEPs) are a broad family of approaches within the humanistic psychology tradition. Major subapproaches include: • person-centered therapy (PCT) • gestalt • emotion-focused therapy (EFT) • motivational interviewing (MI) • psychodrama • focusing-oriented • expressive and body-oriented therapies. Despite differences in technique, all HEPs share several core assumptions. The therapeutic relationship is considered central and potentially curative in itself, going beyond a technical service or an unconscious repetition of past attachments. Instead it is seen as an authentic, boundaried relationship providing the client with a new, corrective and validating emotional experience. All HEPs also emphasize the importance of client experiencing, defined as the holistic process of immediate ongoing awareness that includes perceiving, sensing, feeling, thinking and wanting. Methods that deepen emotional experiencing are used within an empathic and facilitative relationship. HEPs share a phenomenological view of people as meaning-creating agents whose subjective experience is essential. They also share the belief that people are wiser than their intellect alone, and that internal tacit experiencing is fundamentally adaptive and can guide conscious awareness when attention is turned inward within a safe interpersonal context. All HEPs are consistently person-centered, viewing each person holistically rather than as a symptom or diagnosis. After this chapter, you should be able to answer this exam question. Don’t worry if you can’t solve it right now. After studying this chapter, you should be able to solve it yourself. An answer will also be provided at the end of the week for your reference. Which of the following best describes what all HEPs have in common? A) They all use structured, manualized treatment protocols B) They all minimize therapist involvement in guiding the therapeutic process C) They all view the therapeutic relationship as potentially curative and emphasize client experiencing D) They all reject the use of emotional techniques in therapy Please Note! They are sometimes also used by researchers from other orientations as generic control conditions under labels like "supportive" or "nondirective" therapy. Tip! Make sure to remember the commonalities between the different HEP techniques for the exam. Week 5: Humanistic-Experiential Psychotherapies 6 One ongoing debate within HEPs focuses on the degree to which therapists should act as process-experts by actively guiding how clients work on their problems. All HEPs involve some degree of process guiding, but EFT, gestalt, psychodrama and MI are more explicitly process-guiding, while PCT and nondirective therapies attempt to minimize this. Some newer existential approaches such as meaning-centered psychotherapy take an even more explicit content-directive approach and fall outside the HEP family as defined here. Are Humanistic-Experiential Therapies Effective? 2009-2018 Meta-Analysis Update Despite research supporting their effectiveness, HEPs have largely been overlooked in mainstream treatment guidelines such as NICE, which continue to favor CBT. This chapter presents an updated meta-analysis of 91 studies published between 2009 and 2018, following PRISMA guidelines. Meta-Analytic Approach The authors follow an inclusive strategy, using all available data regardless of study quality, including pre-post designs and open clinical trials. This is intended to minimize reviewer bias. Two limitations of previous versions were addressed: primary outcomes and intent-to-treat designs are now included, and a PRISMA diagram is provided. Inclusion criteria required treatments labeled as person-centered, process-experiential, focusing, gestalt, motivational interviewing, or described as using empathy as a key element, with at least three sessions, a sample of at least 10, and clients aged 13 or older. Diversity Issues The current update includes studies from the Middle East, east or south Asia, and from South Africa. Studies also included elderly clients, clients with disabilities and clients from minority backgrounds. Tip! Also remember the differences between the techniques such as the process guiding mentioned above in the text and table 13.1. Week 5: Humanistic-Experiential Psychotherapies 7 Effectiveness Research on Humanistic-Experiential Therapies: Total Pre–Post Change HEPs produce large pre-post effects. The best estimate of overall client change is a per protocol primary outcome effect size of g = 0.86. Clients generally maintained their gains after therapy, with follow-up effects of 0.88 at up to 11 months and 0.92 beyond 12 months. Controlled Efficacy Studies on Humanistic-Experiential Therapies Comparing HEPs to wait-list or no-treatment controls, the weighted mean controlled effect size was 0.88, very similar to the pre-post effect. Untreated control participants showed almost no change (ES = 0.09). Three conclusions follow from this: there is likely a strong causal relationship between HEPs and client change, almost all pre-post gains can be attributed to the therapy itself rather than external factors, and treatment effects appear if anything stronger for RCTs than for nonrandomized studies. Comparative Outcome Research on Humanistic- Experiential versus Other Therapies The overall comparative effect was -0.08, falling within the equivalence range. In 68% of comparisons, the difference between HEP and non-HEP clients was within 0.4 standard deviations, suggesting HEPs are broadly equivalent to other therapies overall. However heterogeneity was very high (I² = 91%), indicating substantial variability across studies. 1) HEPs Versus Cognitive-Behavioral Therapies (CBTs) and Other Therapies The overall comparative effect for studies comparing HEPs to CBT was -0.26, which is equivocally in favor of CBT, a small but not clinically decisive advantage. Results for RCTs were identical. A critical finding however is that 78% of HEP vs. CBT studies showed negative researcher allegiance, and there was a very strong negative correlation between researcher allegiance and comparative effect size. When researcher allegiance was controlled for in RCTs, the advantage for CBT disappeared and results moved toward equivalence. When HEPs were compared to non-CBT therapies, the effect was in the equivalent to trivially better range. 2) CBT Versus HEP Subtypes Supportive-nondirective therapies were equivocally worse than CBT (ES = -0.29), though this was partly explained by the fact that 59% of these were non-bona fide versions of PCT constructed by CBT researchers as control conditions. Person-centered therapy was also equivocally worse than CBT, though this difference reduced when researcher allegiance was controlled for. Comparisons Among Types of Humanistic- Experiential Therapies Among different HEP subtypes, EFT showed the largest pre-post effects, significantly larger than supportive-nondirective therapies which showed the smallest effects. Direct comparisons between HEP subtypes were rare however, and the difference between more and less process-guiding HEPs was only trivially in favor of the more process-guiding approaches, which was not significant. Outcome for Different Client Problems: Differential Treatment Effects The strongest evidence for HEPs has been found for depression, relationship and interpersonal problems, coping with chronic medical conditions, habitual self-damaging behaviors such as substance misuse and eating disorders, and psychosis. Evidence for anxiety is more mixed. Tip! For the exam, remember the most and least effective subtype of HEP. Week 5: Humanistic-Experiential Psychotherapies 8 Depression • Pre-Post Effects: Pre-post effects for depression were large, with high heterogeneity. Most studies involved mild-moderately depressed clients. EFT showed the largest pre-post effects while PCT showed the smallest, though confidence intervals for all HEP types overlapped. • Controlled Effects: Only three controlled studies were available, producing a medium-sized controlled effect. Untreated control participants showed relatively large spontaneous improvement, much higher than the overall sample average (0.09), which may reflect the episodic nature of depression and its tendency toward spontaneous recovery. • Comparative Effects: HEPs were trivially worse than CBT for depression overall, though this was heavily influenced by negative researcher allegiance (17 out of 25 comparisons). When compared only to non-CBT therapies, HEPs were equivalent. One study found equivalent outcomes for humanistic counseling and CBT overall, with counseling outperforming CBT for treatments up to 11 sessions, while CBT was better for 12 or more sessions. The same study found equivalence for more severely depressed clients..The PRaCTICED Trial, a large balanced allegiance RCT, found PCE therapy equivalent to CBT at 6 months but a CBT advantage at 12 months, particularly for more severely depressed clients. Importantly, PCE therapy clients retained their gains after therapy while CBT clients continued to improve during the post-therapy period. Relationship and Interpersonal Difficulties • Pre-Post Effects: HEPs show large pre-post effects for relationship and interpersonal difficulties. Effects were consistent across individual, group and couples/family formats, and did not differ significantly between general interpersonal difficulties and specific relational conflicts. Childhood abuse and complex trauma showed somewhat larger effects than single episode trauma, though the difference was not statistically significant. EFT showed the largest effects compared to person-centered and gestalt therapy, though again confidence intervals overlapped. • Controlled Effects: Controlled effects were large and virtually identical to the pre-post effect, suggesting almost no natural self-healing in this population without treatment. Effects were large for both individual and group formats, and for both EFT and gestalt/psychodrama. Clients with general interpersonal difficulties showed larger controlled effects than those with specific relational difficulties. • Comparative Effects: Comparative effects were worse than non-HEPs overall, though highly heterogeneous. A strong negative researcher allegiance effect was present, and when studies were split by allegiance, pro-HEP studies showed positive effects while negative allegiance studies showed negative effects. HEPs fared most poorly with trauma presentations, particularly simple or complex trauma, while EFT and gestalt showed positive comparative effects. Please Note! Pre-post effects measure how much clients improved from the beginning to the end of therapy, without any comparison group. Controlled effects compare how much clients in therapy improved compared to clients who received no treatment or were on a waiting list, allowing us to determine whether therapy itself caused the change. Comparative effects compare how well an HEP performed against another active treatment such as CBT, telling us whether one therapy is more effective than another. Week 5: Humanistic-Experiential Psychotherapies 9 Conclusions Five explanations are offered: broadening of inclusion criteria may have diluted the evidence, shifts in client subpopulations studied, possible decreased effectiveness of HEPs or use of less effective versions, possibly more effective forms of CBT being developed, and increased negative researcher allegiance. Despite this, EFT for couples remains an empirically supported treatment for marital distress and EFT for individuals remains efficacious for unresolved relationship issues and emotional injuries. Anxiety • Pre-Post Effects: Pre-post effects for anxiety were large, near the overall benchmark for the entire dataset. EFT showed significantly larger effects than supportive-nondirective therapy. The most promising HEP applications were for PTSD, social anxiety and GAD, while effects were substantially smaller for mixed anxiety populations and medically related anxiety. • Controlled Effects: Only three controlled studies were available, producing a large controlled effect, the same as the pre-post effect, suggesting that HEPs produce genuine therapeutic gains for anxious clients beyond what would occur naturally. • Comparative Effects: Comparative effects were clearly negative, with HEPs performing equivocally worse than non-HEPs for anxiety overall. This was the worst comparative result of all six client populations reviewed. Negative researcher allegiance was pervasive (10 out of 13 studies). The main source of this negative effect was PTSD studies comparing supportive-nondirective therapy to CBT, where CBT showed a large advantage. In contrast, for medically related anxiety, HEPs showed statistical equivalence to CBT. • Conclusions: HEPs show large pre-post effects for GAD, social anxiety and PTSD and meet criteria as possibly efficacious treatments, particularly EFT and newer process-guiding approaches such as dialogical exposure therapy. However CBT appears more effective than supportive-nondirective therapy for PTSD specifically. The apparent CBT advantage is likely due to researcher allegiance and because anxiety may respond better to more structured process-guiding approaches that share elements with CBT's exposure work. Coping with Chronic Medical Conditions • Pre-Post Effects: The number of studies on HEPs for chronic medical conditions has doubled since 2013. Pre-post effects were medium-sized overall but highly variable across medical conditions. The largest effects were found for gastrointestinal problems and obesity, early dementia and infertility, while smaller effects were found for early stage cancer and autoimmune conditions. EFT and psychodrama showed the largest pre-post effects, followed by person-centered therapy, while supportive-nondirective therapy showed smaller effects. • Controlled Effects: Five controlled studies produced a medium and highly consistent controlled effect, supporting efficacy of HEPs for this population above no-treatment. • Comparative Effects: The overall comparative effect was equivalence, though highly heterogeneous. Supportive-nondirective therapy was equivocally less effective than other treatments, while the combination of person-centered, EFT and supportive-expressive group therapy was significantly more effective than comparison treatments. HEPs did best compared to treatment as usual and less well compared to CBT and other psychological treatments. Researcher allegiance was a very strong predictor of comparative effect size. • Conclusions: CBT appears equivocally more effective than supportive-nondirective therapy for medical populations, but mainstream HEPs such as person-centered therapy, EFT and supportive-expressive group therapy appear efficacious based on their pre-post effects, superiority to no-treatment controls, and greater effectiveness than non-HEP treatments in some comparisons. However conclusions are limited by researcher allegiance effects, non-bona fide HEPs, and the small number of comparisons between CBT and bona fide HEPs. Week 5: Humanistic-Experiential Psychotherapies 10 Psychosis HEPs for psychosis have been controversial, with guidelines explicitly recommending against offering counseling and supportive psychotherapy to people with schizophrenia, but those were not well supported by the evidence. • Pre-Post Effects: Five RCTs showed moderate to large pre-post effects, though highly heterogeneous. Studies fell into two clusters: pro-HEP studies testing new body movement expressive therapy with schizophrenia patients showed smaller but consistent effects, while negative allegiance studies using non-bona fide supportive-nondirective therapy as a control condition for new CBT approaches showed very large pre-post effects. • Comparative Effects: Six comparative RCTs found a trivially but equivocally positive overall comparative effect, suggesting HEPs perform at least as well as and possibly slightly better than non-HEPs including CBT for psychosis. Results were highly heterogeneous. The CBT vs. supportive-nondirective cluster for high-risk prodromal psychosis produced a near-zero effect, best described as equivocally equivalent. Body movement therapy vs. medication or exercise produced an equivocally better result for HEPs. • Conclusions: Treatment guidelines recommending CBT over HEPs for psychosis are out of date. Habitual Self-Damaging Activities Motivational interviewing (MI) is the most researched HEP for self-damaging activities but was excluded from this meta-analysis. The most recent MI meta-analysis found small consistent effects over wait-list and equivalence with active treatments like CBT. MI is often incorrectly portrayed as a form of CBT rather than as part of the HEP family. • Pre-Post Effects: Eight non-MI studies produced large pre-post effects. Effects were much larger for eating difficulties than for other self-damaging activities. EFT and person-centered therapy showed the largest pre-post effects. • Controlled: Only one controlled study found no difference between HEP and wait-list. • Comparative Effects: Six comparative studies found equivalence between HEPs and non-HEPs overall, though with high heterogeneity and a very strong researcher allegiance effect. Studies with pro-HEP allegiance favored HEPs strongly while negative allegiance studies favored non-HEPs. Process-guiding HEPs for eating difficulties showed positive results, while supportive-nondirective therapy for substance misuse and self-harm fared less well. • Conclusions: Process-guiding HEPs are possibly efficacious for eating difficulties are also likely useful for substance misuse, though the evidence is weaker. Other Client Populations 21 studies covering general or mixed client populations, nonclinical populations, prisoners and various other groups were also reviewed. Pre-post effects were large and near the overall benchmark. Controlled effects were large but highly heterogeneous, with school-based humanistic counseling for young people showing medium-sized controlled effects. Comparative effects fell in the trivially worse but statistically equivalent range, with researcher allegiance playing a moderating role. Most comparative studies used person-centered or supportive-nondirective therapy, with generally equivalent outcomes to CBT in mixed populations. Qualitative Research on Humanistic-Experiential Psychotherapies Update on Qualitative Outcomes in Humanistic- Experiential Psychotherapies Based on studies and a large meta-analysis, three main outcome categories emerged: • appreciating experiences of self • appreciating experience of self in relation to others • changed view of self and others Week 5: Humanistic-Experiential Psychotherapies 17 Using Humanistic and Existential Therapies These therapies emphasize empathy, reflective listening, emotional honesty, and authentic relationships. Therapists help clients understand how their thoughts and experiences shape the meaning they give to life events and encourage them to make healthier choices. Essential Skills The therapist’s personal qualities are extremely important in these approaches. Therapists must be genuine, empathetic, emotionally present, and able to build trusting relationships with clients. When To Use Brief Humanistic and Existential Therapies Different approaches are useful for different situations. Client-centered therapy helps build trust, existential therapy addresses fear and responsibility, narrative therapy helps clients rewrite destructive life stories, Gestalt therapy increases present-moment awareness, and transpersonal therapy focuses on spirituality and personal transformation. Duration of Therapy and Frequency of Sessions These therapies work well in brief treatment because they quickly strengthen the therapeutic relationship and encourage clients to take responsibility for change. Growth is expected to continue between therapy sessions as clients apply insights to daily life. Initial Session The first therapy session focuses on building trust, encouraging hope, and helping clients recognize that entering treatment is an important personal choice. Therapists also help clients clarify goals and expectations for recovery. Compatibility With 12-Step Programs Humanistic and existential therapies share several important similarities with 12-Step programs such as Alcoholics Anonymous. Both approaches encourage honesty, self-examination, acceptance of limitations, and ongoing personal growth. The Serenity Prayer, for example, reflects existential ideas about accepting what cannot be changed while courageously changing what can be changed. At the same time, some existential therapists question the idea of defining people primarily through a “disease identity” or emphasizing powerlessness. Existential therapy values free will and personal responsibility. However, surrender within a 12-Step program can still be understood as a conscious and meaningful personal choice. Tip! Many humanistic and existential therapists believe that substance abuse is not only a behavioral problem but also a sign of deeper emotional pain, hopelessness, or spiritual emptiness. Recovery therefore involves creating a more meaningful and emotionally fulfilling life. Tip! The concept of “apperception” is important because it explains that people do not simply experience events objectively. Instead, they interpret events through their emotions, memories, beliefs, and expectations, which shapes how they respond to life. Week 5: Humanistic-Experiential Psychotherapies 18 Research Orientation Humanistic and existential therapists often prefer qualitative research methods because they focus on personal meaning and subjective experience rather than only measurable behavior. Carl Rogers helped pioneer research on the therapeutic relationship. The Humanistic Approach to Therapy Humanistic psychology emphasizes personal growth, self-actualization, and human potential. Important figures include Abraham Maslow, Carl Rogers, and Fritz Perls. The approach views people holistically and values empathy, authenticity, and collaboration in therapy. Client-Centered Therapy Client-centered therapy, developed by Carl Rogers, is based on empathy, acceptance, and unconditional positive regard. Rogers believed that people naturally move toward growth when they feel understood and emotionally safe. This approach is especially useful in addiction treatment because it reduces shame and increases motivation for change. Narrative Therapy Narrative therapy helps clients understand how life stories shape identity and behavior. Therapists encourage clients to separate themselves from addiction, identify strengths, and develop more hopeful and empowering personal narratives. Transpersonal Therapy Transpersonal therapy combines psychology with spirituality and focuses on expanded awareness, mindfulness, and personal transformation. It views addiction as partly connected to spiritual emptiness and encourages clients to find meaning, connection, and inner peace. Tip! Although existential therapy values freedom and personal choice, many existential therapists still appreciate the role of surrender in recovery programs if surrender is understood as a conscious and meaningful decision. Tip! Humanistic psychology is often called the “third force” because it developed as an alternative to both behaviorism and psychoanalysis. It emphasizes hope, personal meaning, creativity, and the positive potential of human beings. Tip! Transpersonal therapy explores experiences that go beyond ordinary awareness, including spirituality, meditation, intuition, and feelings of deep connection with others and the world.

Introduction and Historical Context This lecture focuses on Client-Centered Therapy (CCT), developed by Carl Rogers. The lecture situates CCT historically by comparing it with psychoanalysis and behaviorism. At the end of the nineteenth century, psychoanalysis dominated psychology through Freud’s theories about unconscious drives, defense mechanisms, and instinctual motivation. Human behavior was largely understood as driven by unconscious desires and conflicts. In 1913, behaviorism emerged through John B. Watson, who rejected introspection and focused instead on observable behavior and experimental research. This movement later contributed to the development of cognitive behavioral therapy. Week 5 The summary of WEEK 5 helps you quickly understand the core of Humanistic-Experiential Therapies and apply it to exam questions. You will learn: • Historical Context • Carl Rogers • Core Conditions of CCT • Qualities of a CCT Therapist This material accounts for approximately 14% of the exam. Week 5: Humanistic-Experiential Therapies 5 Humanistic psychology emerged as a reaction against both psychoanalysis and behaviorism. Together with Abraham Maslow, Rogers introduced what became known as the “Third Force” in psychology. Humanistic psychology emphasized: • Human freedom and choice • Subjective experience • Personal responsibility • Individual uniqueness • Growth and self-development Unlike deterministic models, humanistic psychology viewed people as fundamentally capable of growth and self-direction. Carl Rogers and the Development of CCT Carl Rogers believed deeply in people’s capacity for growth and change. He argued that clients are not passive recipients of treatment but active experts on their own experiences. A key turning point occurred when Rogers realized that trying to instruct or direct clients often created resistance. Instead, genuine listening and empathic understanding helped clients become more open and self-reflective. Initially, Rogers called his approach “non-directive therapy” because he deliberately avoided: • Giving advice • Moralizing • Directing conversations • Acting from a distant professional role Later, he renamed the approach “client-centered therapy,” emphasizing that therapy should revolve around the client’s inner process rather than the therapist’s expertise. Theoretical Framework of CCT Rogers’ concept of the actualizing tendency: the natural human drive toward growth, autonomy, self-regulation, and fulfillment. Tip! Client-Centered Therapy emerged as the “Third Force” in response to psychoanalysis and behaviorism. Unlike earlier approaches that focused on unconscious drives or observable behavior, humanistic psychology emphasizes personal experience, choice, and the natural capacity for growth and self-direction. Tip! Rogers believed clients are active experts in their own experience. He found that change happens less through advice and more through empathic listening and genuine understanding. This shift led from “non-directive therapy” to “client-centered therapy,” where the client’s inner process guides the work. Week 5: Humanistic-Experiential Therapies 6 According to Rogers: • Human beings strive toward psychological growth • Individuals possess an inherent capacity for healing • Psychological distress arises from incongruence between experience and self-concept Incongruence occurs when people deny, distort, or reject parts of their emotional experience in order to meet external expectations or conditions of worth. Therapy aims to reduce this incongruence so individuals can live more authentically. Core Conditions of Therapy Rogers identified several therapeutic conditions necessary for growth. 1. Empathy: The therapist attempts to deeply understand the client’s subjective experience and emotional world. 2. Congruence: The therapist remains genuine, authentic, and transparent rather than hiding behind a professional façade. 3. Acceptance: Often referred to as unconditional positive regard, acceptance means valuing the client without judgment. These conditions create an environment in which clients feel safe enough to explore vulnerable emotions and experiences. What Does a CCT Therapist Do? Client-centered therapists focus less on techniques and more on relational presence. Tip! Rogers proposed an actualizing tendency—an innate drive toward growth and self-fulfillment. Psychological distress comes from incongruence, when lived experience is denied or distorted to meet external expectations. Therapy helps reduce this gap so people can live more authentically. Tip! Rogers highlighted three key conditions for growth: empathy, congruence, and acceptance. When the therapist is genuine, deeply understanding, and non-judgmental, clients feel safe enough to explore vulnerable emotions and begin to change. Examples: A CCT therapist: • Listens actively and carefully • Demonstrates empathy and involvement • Creates emotional safety • Trusts the client’s growth capacity • Asks exploratory questions • Shows patience • Focuses on the therapeutic process • Stays close to the client’s emotional experience • Helps deepen awareness of feelings • Works collaboratively rather than hierarchically

Environmentallyextended input-output analysis(EE-IOA) focuses on the biophysical and monetary interrelations between economic sectors. It linksproduction, consumption and environmental stressors within and across countries. EE-IOA goes back to the work of Wassily Leontief (Fig2)86and has been proposed early on as a means to “integrate the world of commodities into the larger economy of nature”87

Although core memory is obsolete, computer memory is still sometimes called "core" even though it is made of semiconductors, particularly by people who had worked with machines having actual core memory. The files that result from saving the entire contents of memory to disk for inspection, which is nowadays commonly performed automatically when a major error occurs in a computer program, are still called "core dumps". Algorithms which work on more data than the main memory can fit are likewise called out-of-core algorithms. Algorithms which only work inside the main memory are sometimes called in-core algorithms.

Following this observation, the same group conducted a cross-sectional analysis to assess the association among 140 patients with EE and TH replacement hypothyroid treated with LT4. In this study population, REE did not differ significantly between patients achieving low-normal (TSH ≤ 2.5 μIU/mL) vs high normal TSH (TSH >2.5 μIU/mL). Conversely, free T3 level showed a direct correlation with EE, but also with indices of adiposity including body mass index (BMI), body composition, and fat free mass [49]. This latter observation is consistent with other cross-sectional studies that have clearly defined the positive association between circulating levels of T3 and adiposity [50, 51].

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