Person-Centred Therapy

Origins of Client-Centered Therapy

Rogers first called his method non-directive therapy. He renamed it client-centered therapy because critics argued that “non-directive” described only what the therapist withheld, not what the therapy offered.

From the mid-1970s it became known as person-centered therapy. The new name signals that the whole person, not only the presenting problem, is the focus.

Humanistic therapies evolved in the USA during the 1950s. Rogers co-founded this humanistic psychology “third force” with Abraham Maslow and Rollo May, as an alternative to psychoanalysis (the first force) and behaviorism (the second).

Carl Rogers proposed that therapy could be simpler, warmer, and more optimistic than that carried out by behavioral or psychodynamic psychologists.

His view differs sharply from the psychodynamic and behavioral approaches. Rogers suggested that clients would be better helped by focusing on their current subjective understanding, not on some unconscious motive or someone else’s interpretation of the situation.

It emerged from his early work with troubled children in 1939 and later expanded to include work with couples, families, and groups.

Rogers’ most comprehensive theoretical statement was published in 1959, encompassing his theories of motivation, personality development, group interaction, and interpersonal relationships.

The approach emphasizes the client’s inherent capacity for self-knowledge and self-healing within a specific, facilitative therapeutic climate.

It is practiced globally. WAPCEPC, the World Association for Person-Centered and Experiential Psychotherapy and Counseling, and ADPCA, the Association for the Development of the Person-Centered Approach, promote its growth.

Core Conditions of Person-Centered Therapy

The therapeutic relationship is the critical variable, not what the therapist says or does.

In person-centered therapy, the therapeutic relationship is considered profoundly central and is theorized to be the primary engine of constructive personality change.

Carl Rogers’ theory posits that a definable climate of facilitative conditions within the relationship is necessary and sufficient for change and development to occur.

Rogers (1957) listed six conditions. They must exist and continue over a period of time for constructive personality change.

He framed this as a testable hypothesis that did not depend on any one school of therapy.

Three of the six are known as the core conditions: congruence (genuineness), unconditional positive regard (warm, non-judgmental acceptance) and empathic understanding (sensing the client’s inner world accurately).

Rogers’ 6 Conditions for Change	Description
1. Psychological contact	A working connection between therapist and client
2. Client incongruence (anxious or vulnerable)	Client is in a state of inner conflict (distress)
3. Therapist congruence (genuineness)	Therapist is real and transparent with the client
4. Therapist unconditional positive regard	Therapist fully accepts the client without judgment
5. Therapist empathic understanding	Therapist deeply understands the client’s feelings
6. Minimal communication of UPR/empathy	Client at least senses the therapist’s acceptance and understanding​

Rogers’s 1957 Paper: A Testable Hypothesis

The paper’s strength is its atheoretical, falsifiable framing. Because the conditions were defined independently of any school, psychodynamic, behavioral and humanistic researchers could all test them.

That seeded a “common factors” research tradition, the study of what different therapies share.

Its weakness is the strength of the claim itself. Later research supports the conditions as facilitative and predictive of outcome, but has not established them as jointly sufficient (see the Evidence Check below).

1. Two persons are in psychological contact:

This is the fundamental precondition: the client and therapist are to some degree in contact. Each perceives, or “subceives”, that the other makes a difference in their experiential field.

Without this basic connection, the other conditions have no meaning.

2. The client is in a state of incongruence, being vulnerable or anxious.

This condition focuses on the client’s internal state at the outset of therapy.

Incongruence is a gap between the client’s actual experience at an organismic level (what they sense and feel as a whole person, moment to moment) and their self-concept.

The individual’s awareness, which forms their self-concept, may not accurately represent that deeper experience.

For example, someone may feel a deep fear of inadequacy. If this conflicts with their self-concept, they might symbolize it in awareness as an unrelated fear, like being afraid of stairs.

A mother may deeply want to hold onto her son. If her self-concept says that “good mothers” don’t have such desires, she may experience it as physical illness instead.

The result is a basic incongruence between the perceived self and the actual experience.

The presence of incongruence makes the client either vulnerable or anxious:

• If the client has no awareness of this incongruence, they are considered vulnerable. They are susceptible to experiencing anxiety or disorganization if an experience occurs that is so sudden or obvious that the incongruence cannot be denied.
• If the client dimly perceives or subceives this incongruence, they experience a state of tension known as anxiety. Subceiving means discriminating something as threatening to the self without conscious awareness of the specific content of the threat. This anxiety is often observed in therapy as the client approaches awareness of experiences that sharply contradict their self-concept.

Rogers hypothesized that this state of incongruence, leading to vulnerability or anxiety, is necessary to initiate the process of constructive personality change.

It suggests a level of distress or discomfort that provides the motivation or readiness for change to occur within the therapeutic relationship.

Operationally defining this condition can be challenging. One method suggested by Rogers involves using Q sorts.

A client’s self-concept can be defined by sorting a list of self-referent items based on their self-perception.

The client’s total experiencing could be crudely represented by a clinician sorting the same items based on information from projective tests, which might include unconscious elements.

The correlation between the two sorts could serve as an operational measure of incongruence. Low or negative correlation means high incongruence.

Like most of the other conditions (2 through 6), the client’s incongruence, with its vulnerability or anxiety, exists as a matter of degree. It is not simply present or absent.

The more fully this condition exists alongside the other facilitative conditions, the more marked the constructive personality change is hypothesized to be.

3. The therapist is congruent or integrated in the relationship:

Congruence, also called genuineness, means the therapist is freely and deeply themselves in the relationship, with their actual experience accurately represented by their awareness.

According to Rogers, congruence is the most important attribute in counseling. Without it, the other two core conditions risk becoming a performance rather than a lived stance.

Congruence has several features:

• Inner Wholeness: A state of internal integration. The therapist is not distracted by their own concerns and can be fully present with the client.
• Self-Acceptance: It stems from the therapist’s self-acceptance, positive self-regard and evolving self-awareness, without inner censorship.
• No Facade: It is the opposite of presenting a facade. The therapist’s internal and external experiences are one and the same.
• Transparency: It shows as genuineness, so the client feels they are with a real person, not someone enacting a role.
• Not Full Disclosure: The therapist need not voice every feeling or self-disclose, but must have no false front and be willing to be known.
• Clinical Manner: A new therapist who adopts a stiff, formal manner because they think a professional should sound that way is being incongruent.

In short, the therapist is authentic.

4. The therapist experiences unconditional positive regard for the client:

Unconditional positive regard is the therapist’s deep and genuine caring for the client, shown as warm, non-judgmental acceptance of every aspect of their experience.

It is the direct antidote to the conditional regard that first installed the client’s conditions of worth, the standards of approval they absorbed from others.

• No Conditions: The therapist accepts experiences the client sees as “good” or “bad,” positive or negative, consistent or inconsistent.
• Prizing the Person: The client is valued as a separate individual with the right to their own feelings and experiences.
• Accepting the Person: The therapist may not approve of some actions but still approves of the client: “I’ll accept you as you are.”
• Not Possessive: It is the opposite of a selective, evaluating attitude. The therapist cares without being possessive or meeting their own needs.
• A Matter of Degree: It is an ideal that exists on a continuum in any relationship, so therapists strive for greater acceptance.

The person-centered counselor therefore keeps a positive attitude toward the client, even when disgusted by the client’s actions.

5. The therapist experiences an accurate, empathic understanding of the client’s internal frame of reference and endeavors to communicate this experience.

Empathy is the ability to understand what the client is feeling, sensitively and accurately but not sympathetically. In therapy, empathic understanding means sensing the client’s internal frame of reference as if it were your own, while keeping the “as if” quality.

In practice, it has four parts:

• Staying Separate: The therapist senses the client’s private world without losing their own identity or perspective, and without making judgments.
• Moment-to-Moment Sensing: The therapist follows changing felt meanings, such as fear, rage, tenderness or confusion, as they unfold in the session.
• Delicate Attention: The therapist moves about in the client’s world delicately, sensing meanings the client may be scarcely aware of.
• Checking Accuracy: The therapist expresses the meanings back to the client to check they are right, so the client knows they are understood.

A short example shows the difference. Suppose a client says, “I don’t want to go into work today. People are going to judge me.”

• Directive Response: The therapist might reassure (“Don’t worry what they think”), problem-solve or interpret (“That sounds like your father’s voice”).
• Empathic Response: The therapist stays inside the client’s frame: “You don’t want to go in today. You’re expecting to be judged?”
• Next Turn: The client adds, “They might see me as stupid, and I don’t want to feel that.” The therapist reflects only that: “You don’t want to feel stupid.”

At each turn, the therapist tracks the client’s developing understanding of their experience. They do not substitute their own sense of what matters.

In the words of Rogers (1959), accurate empathic understanding is as follows:

“The state of empathy, or being empathic, is to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the “as if” condition.

Thus, it means to sense the hurt or the pleasure of another as he senses it and to perceive the causes thereof as he perceives them, but without ever losing the recognition that it is as if I were hurt or pleased and so forth. If this “as if” quality is lost, then the state is one of identification” (p. 210-211).

6. The communication to the client of the therapist’s empathic understanding and unconditional positive regard is to a minimal degree achieved.

The foundation of person-centered therapy rests on two essential therapeutic conditions:

• Empathic understanding: The therapist’s ability to accurately perceive the client’s internal frame of reference
• Unconditional positive regard: The therapist’s non-judgmental acceptance of the client

For therapy to be effective, the client must perceive these conditions. It is not enough for a therapist to believe they are being empathic or accepting; their behaviors and words must be recognized by the client as communicating understanding and acceptance.

Distinguishing True Empathy from Technique

A crucial distinction exists between:

1. A therapist who simply repeats back client words to convey empathy as a technique
2. A therapist who responds empathically to check their own understanding of the client’s experience

The technique of “reflecting feelings” has sometimes been associated with person-centered therapy but has occasionally been caricatured as mere parroting.

That caricature misses the authentic intent of the approach.

Client-centered therapists make a sincere effort to grasp the meanings the client expresses. When done authentically, the client’s experience of being understood emerges as a natural byproduct of that effort, rather than a calculated technique.

Clients readily sense the difference between a therapist genuinely trying to grasp their meaning and one performing a script.

Why is nondirectiveness a key attitude in Person-centered therapy?

Nondirectiveness is the attitude that lets the therapist genuinely embody the core conditions (congruence, unconditional positive regard, and empathic understanding). It rests on deep respect and trust in the client, and it facilitates the client’s own self-discovery and constructive personality change without imposing the therapist’s agenda or expertise.

Principled nondirectiveness is a unique commitment in person-centered therapy, stemming from a deep respect for the client’s self-realizing capacities and right to self-determination.

The therapist sets no goals and gives no assignments. They also do not direct the process or content of therapy based on their own beliefs about what matters or how the client should relate to their concerns.

The therapist’s only acceptable goals are for themselves: to embody the attitudes of congruence, unconditional positive regard, and empathic understanding.

No therapy is entirely free of influence. Still, the disciplined attempt to minimize influence and power over the client is central to the person-centered approach. It aims to empower the client to become more authoritative in their own lives.

Nondirectiveness aligns with the approach’s core principles and goals in seven ways:

1. Respect: The client is treated as a sovereign being of inexhaustible depth and meaning, not as an object.
2. Trust: Clients hold inner resources for self-knowledge and healing, so the therapist need not set goals or direct the work.
3. Client Agency: Minimizing the therapist’s influence and power over the client empowers the client.
4. Means and Ends: A therapy that aims at autonomy must itself be practiced in a way consistent with that aim.
5. Subjective Reality: Attention stays on the client’s internal frame of reference, not on diagnosing or speeding up the process.
6. Growth: Letting the client lead fosters self-assertion, confidence, openness and self-direction.
7. Client-Set Outcomes: Only goals the client articulates and seeks count; therapist-imposed outcomes such as homework do not.

1. Respect for the Client as a Sovereign Being:

The foundation of client-centered practice rests on the therapist’s respect for and personal openness to the client as a sovereign being of inexhaustible depth and meaning.

It involves encountering the client personally, acknowledging them as the Other, rather than objectifying them.

Nondirectiveness embodies this respect by affirming the client’s inherent worth and capacity. Even gentle direction carries a message. It implies that the therapist, not the client, knows what the client needs.

2. Trust in the Client’s Capacity for Self-Direction and Healing:

Person-centered therapy is grounded in the belief that persons possess resources of self-knowledge and self-healing and have an inherent capacity for self-determination.

The therapist holds the hypothesis that the client possesses the inner resources to meet life’s difficulties.

Nondirectiveness is a logical extrapolation from the motivational theory (specifically, the actualizing tendency) which posits that organisms strive to realize their potentials.

Trust makes the client the architect of their own life. The therapist therefore need not set goals, give assignments, or direct the relationship.

3. Empowerment and Preservation of Client Agency:

The client-centered approach consciously and deliberately strives to minimize influence upon or power over the client.

A disciplined attempt to preserve the client’s freedom and safety in the relationship creates a distinctive relationship which empowers the client.

Therapist-initiated direction is seen as potentially:

• exerting influence over the client
• reinscribing a model of power over the client
• reiterating the subordination of the client as a receptacle of knowledge from the therapist as an authority figure

By contrast, the non-directive attitude allows the therapist to value the subjective reality of the client, which ultimately empowers them.

4. Consistency of Means and Ends:

A fundamental argument in person-centered therapy is that the means (the therapeutic approach) must be consistent with the ends (the desired outcomes).

The ultimate goal is to foster a person who is more autonomous, free, and capable of deciding their own goals. The therapy itself must be consistent with these goals.

Therapist direction, assignment of homework, or attempts to influence the client are considered contradictory to the aim of trusting the client’s experience as a trustworthy guide.

Therapist-set goals or assigned homework may foster dependency or undermine the client’s self-esteem and confidence in their own ability to generate adaptive behavior and meaning.

5. The Client’s Subjective Reality:

The non-directive attitude allows the therapist to focus on grasping the client’s internal frame of reference through empathic understanding.

This deep attention values the client’s subjective reality. It does so even when their views may seem irrational or distorted.

The therapist becomes intensely, continuously, and actively attentive to the client’s feelings. Other kinds of attention, such as diagnosing or trying to speed up the process, fall away.

6. Facilitating Client Growth and Self-Sufficiency:

Clients develop valued ways of being in therapy, such as becoming more self-assertive, confident, and open. These seem to result from the lived value of non-directiveness, which fosters profound respect for the client’s choices and self-direction.

Letting the client lead creates a fertile medium. In it, the client’s views of self, others, and the world can change toward greater acceptance and connection with consensual reality.

Client-initiated goals and experiments are welcomed, and the therapist’s acceptance, regardless of follow-through, means resistance is not an issue.

7. Avoiding Therapist-Imposed Outcomes:

Non-directive person-centered therapists critique practices like homework on ethical grounds. They put respect for the other person above the attainment of behavior change or any goals the client has not articulated and sought.

The client decides whether therapy’s change is worthwhile.

Therapists’ acceptable goals are those related to their own ability to realize the core conditions (congruence, unconditional positive regard, and empathic understanding).

The Direction of Change

Rogers described the outcome of therapy as a direction of movement. It is not a fixed cure.

Clients who experience sustained acceptance and empathy tend to move:

• Away From: Facades, living by “oughts,” and pleasing others for its own sake.
• Toward: Self-direction, openness to experience, acceptance of others, and trust in their own organismic sensing (Rogers, 1961).

Rogers called this trust the organismic valuing process. It is moment-to-moment trust in one’s own whole-person sensing of a situation. He held that it proved a more reliable guide than intellect alone.

On this view, “the good life” is not a state of arrival such as contentment, virtue, or a fixed identity. It is an ongoing process.

That process means full openness to experience, living in the present rather than by rigid preconceptions, and a growing willingness to trust and take responsibility for one’s own choices.

Person-Centered Approach

Rogers (1959) developed what he called client-centered or person-centered therapy, named for its focus on the person’s subjective view of the world.

This was a deliberate departure from psychoanalysis and behavioral therapies, where doctors in positions of authority diagnosed and treated patients.

A person typically enters person-centered therapy in a state of incongruence, a discrepancy between their self-concept and their actual experience.

The therapist’s goal is not to “fix” this incongruence. It is to create conditions where clients can resolve it themselves through personal growth and eventually self-actualization.

One major distinction between humanistic counselors and other therapists is that they refer to those in therapy as “clients,” not “patients.”

This terminology signals equal partners rather than expert and patient.

The approach consciously and deliberately strives to minimize influence upon or power over the client. Therapist-initiated direction is seen as exerting influence. It reinforces a model of the therapist as an authority figure with knowledge the client lacks.

The Therapeutic Relationship

The disciplined attempt to preserve the client’s freedom and safety in the relationship creates a distinctive dynamic which empowers the client.

This empowerment comes from the therapist’s consistent, deep attention to grasping the client’s internal frame of reference, which communicates a profound valuing of the client’s subjective reality.

Acceptance and non-directiveness create a fertile medium in which the client’s views of self, others, and the world can change toward greater acceptance and connection with consensual reality.

The client feels safe. They can share experiences, initiate goals, and experiment without fear of judgment or being pushed by the therapist.

Client’s Role and Empowerment

Person-centered therapy explicitly places responsibility for change on the client rather than the therapist, setting it apart from more directive therapeutic approaches.

• No Sorting Out: The counselor does not “sort out” problems or offer solutions.
• Facilitated Exploration: The therapist facilitates the client’s own exploration, helping them become increasingly self-aware, independent, and confident in managing their issues.
• Their Own Therapist: The ultimate aim is to empower clients to become their own therapists, nurturing self-confidence, autonomy, and trust in their own perceptions and choices.

This empowerment stems from the core belief that the client is the true expert on their own experience.

Focus on the Person vs. the Problem

Person-centered therapy emphasizes the individual rather than problems or diagnoses.

Rogers intentionally inverted the traditional therapeutic paradigm, which often prioritizes identifying and addressing a patient’s disorder. He advocated concentrating instead on the client’s unique perspective, feelings, and personal experience.

Personal growth comes first. Rogers notably downplayed formal diagnoses and expert interpretations, favoring the client’s subjective and deeply personal experience.

This sets it apart from clinical therapies built around problem-solving and symptom reduction.

Person-Centered Therapy Compared With Other Approaches

Person-centered therapy differs from other major approaches mainly in how directive the therapist is.

Approach	How the therapist works	Contrast with person-centered therapy
Psychodynamic therapy	Interprets unconscious conflict and defense as an expert	Both value the relationship, but person-centered therapy withholds interpretation and treats the client as the only legitimate authority on their own experience
Cognitive-behavioral therapy (CBT)	Structured and time-limited, built around techniques such as cognitive restructuring, behavioral experiments, exposure and homework	No equivalent technique and no therapist-set agenda. CBT’s evidence is strongest for narrowly defined problems (specific phobias, panic, OCD); person-centered evidence is strongest for broader distress, identity and relationship difficulties
Rational emotive behavior therapy (REBT)	Ellis directly challenges irrational beliefs, arguing that disputing distorted thinking brings faster symptom relief	With Gloria, Rogers reflected her conflicting feelings and declined to tell her what to do, while Ellis challenged her beliefs about needing her daughter’s approval
Logotherapy	Active, structured technique aimed at helping the client find meaning, including Socratic dialogue	Shares the optimistic view of human growth but pursues it through technique rather than studied non-directiveness

Core Theory: Actualizing Tendency and Self-Concept

Central to Rogers’s theory is the belief in an innate drive toward self-actualization, meaning that given the right therapeutic conditions, individuals naturally strive toward growth and fulfilling their potential.

This actualizing tendency is fundamental to person-centered therapy. It underscores the therapist’s role in creating an environment conducive to personal growth.

Rogers saw people as essentially trustworthy. Given a supportive climate, the tendency moves a person toward health. This is much as an unimpeded plant grows toward light.

The concept of self-concept and incongruence is closely linked to this idea.

Rogers described incongruence as a discrepancy between a person’s real experiences and their perceived self-image, often developing through internalized expectations known as “conditions of worth.”

These conditions, which are typically absorbed from significant others or society, lead individuals to deny or distort their true feelings to gain acceptance.

Psychological distress arises from these distortions in the self-concept.

Rogers’s core conditions, particularly unconditional positive regard,  are designed specifically to counteract these damaging conditions of worth, allowing clients to reconnect with and authentically express their genuine feelings.

Understanding this theoretical foundation highlights why the core conditions of empathy, congruence, and unconditional positive regard are essential to effective person-centered therapy.

Therapeutic Techniques

There is an almost total absence of specific techniques in Rogerian psychotherapy, due to the unique character of each counseling relationship.

Instead, the quality of the relationship matters most. The relationship, rather than technical interventions, is viewed as the primary catalyst for the client’s healing and growth.

Reflection is the closest the approach comes to a technique: restating, paraphrasing, or gently naming an emerging feeling. Even this is secondary to the underlying attitude.

Because the person-centered counselor places so much emphasis on genuineness and being led by the client, time and technique boundaries matter less than they do to a psychodynamic therapist. A person-centered counselor might diverge considerably from orthodox counseling techniques if they judged it appropriate.

As Mearns and Thorne (1988) point out, we cannot understand person-centered counseling by its techniques alone. The counselor views human nature positively and optimistically.

People are essentially good, and ultimately the individual knows what is right for them. This philosophy is the essential ingredient of successful person-centered therapy, which is “all about loving.”

Learning Check

Joyce is a successful teacher and is liked by her colleagues. However, Joyce has always dreamed of becoming a ballroom dancer.

She spends much of her free time with her partner practicing elaborate lifts and can often be seen twirling around the classroom during break times. Joyce is considering leaving teaching and becoming a professional dancer.

Her colleagues described her plans as ‘ridiculous.’ Her parents are very proud that their daughter is a teacher. They have told Joyce that they will not speak to her again if she does leave teaching to become a dancer. Joyce is beginning to feel sad and miserable.

Referring to features of humanistic psychology, explain how Joyce’s situation may affect her personal growth. [8 marks].

The Gloria Films: Client-Centered Therapy in Practice

The Gloria Films series, taped in 1965, features a real client named Gloria who courageously agreed to be filmed in therapy with three distinguished therapists (Shostrom, 1965).

The films let people sit in on what is ordinarily a very private experience and see what really transpires.

No film series like this had been made before.

The series includes Dr. Carl Rogers demonstrating client-centered therapy, Dr. Friedrich Perls demonstrating gestalt therapy, and Dr. Albert Ellis demonstrating rational emotive therapy. Each therapist briefly describes their system, demonstrates their work, and then comments on it.

How does the Rogers-Gloria interview specifically demonstrate client-centered therapy?

Throughout the session, Rogers remains consistently empathic and non-directive, actively listening to Gloria’s concerns and reflecting her feelings back to her without imposing his own judgments or solutions.

This approach demonstrates the essence of unconditional positive regard, as Rogers accepts Gloria’s experiences and emotions fully, creating a safe environment for her to explore her thoughts.

Gloria leads the conversation. Rogers clarifies her feelings rather than steering her toward any particular outcome. This vividly shows how client-centered therapy can foster self-discovery, personal growth, and an enhanced sense of self-worth.

The interview demonstrates client-centered therapy through several aspects:

• • Rogers’ Explanation: Rogers explicitly stated at the beginning his belief that creating the proper climate and conditions leads to therapeutic movement, and he described the key conditions he aimed to provide: genuineness/congruence, prizing/acceptance, and empathic understanding.
  • Rogers’ Experience: In his comments after the interview, Rogers reflected on his subjective experience of attempting to be genuinely present and congruent in the relationship, feeling oblivious to the artificial setting and living the relationship “in the moment of its occurrence”. He felt moved by Gloria’s expressions and felt he and Gloria “really encountered each other”.
  • Gloria’s Experience: Gloria’s statements during and after the interview indicate her perception of key client-centered conditions. She said she felt understood and that Rogers was supporting her inner sense of direction, feeling a “backing up” from him. She also felt close to him and noted he was “not giving me advice”.
  • Focus on Inner World and Feelings: Rogers’ intent to enter Gloria’s world of experience and sensitively sense her feelings aligns with the approach’s focus. Gloria expressed her inner conflict, guilt about lying to her daughter, her desire for honesty and acceptance, her struggle with risk, her self-judgment, and her feelings of discomfort and seeking an inner “utopia”. Rogers responded by attempting to reflect and understand these internal states, such as when he sensed her contradiction or her feeling “right about me” in “utopian moments”.
  • Observed Therapeutic Change: Rogers observed a shift in Gloria’s narrative during the brief session. She moved from talking about past feelings and behaviors she didn’t own, looking outside for evaluation, to experiencing and expressing feelings in the immediate moment, showing greater awareness of her ability to make her own judgments and choices. This is described as moving from the “there and then” to the “here and now”.

What were some of the key themes explored in the Rogers-Gloria session?

The main problematic facets Gloria presented to Rogers were her difficulty in addressing sexual issues, particularly regarding her daughter, and her feeling of not being understood by her father.

These underlying concerns related to a need to be accepted by others and a feeling of inferiority when she didn’t meet expectations.

Innovative themes that emerged as Gloria explored these problems with Rogers included:

• • Clarification of what to do regarding my daughter: Exploring the dilemma of lying vs. being honest and its potential consequences.
  • Feeling right about me: Realizing that acting according to her feelings reduced guilt and led to a sense of well-being, seeking an inner “utopia”.
  • Accepting myself: Moving towards self-approval, starting with understanding the need for acceptance.
  • Asserting myself: Developing an alternative to seeking external validation, involving critique of her father and new perceptions about her need for his appreciation.

Gloria’s Problematic Self-Narratives

In her Rogers session, Gloria articulated several problematic self-narratives.

A central theme revolved around her difficulties in dealing with sexual issues, particularly in relation to her children and her own feelings of guilt.

She struggled with being honest with her daughter about her sex life after her divorce, fearing disapproval and impacting their open relationship.

She also felt misunderstood by her father. She felt he always expected her to be perfect and could not communicate in a truly understanding and caring way.

These difficulties fed her internal conflict. She felt a discrepancy between the “sweet” picture she wanted to present and what she perceived as her “shady side.”

What Gloria Wanted From Rogers, and How He Responded

Gloria strongly wanted Rogers to give her an answer. She asked him to tell her whether being honest with her daughter about her sex life would negatively affect her.

She wanted him to tell her to be honest. She wanted assurance that her daughter would accept her. In essence, she sought authority and reassurance to relieve her guilt and fear of taking responsibility for the outcome.

Dr. Rogers, consistent with his client-centered approach, refrained from giving direct advice. He did not tell her what to do.

Instead, he validated her desire for an answer while emphasizing that this was a deeply personal matter he couldn’t resolve for her.

He stated his commitment to helping her work toward her own answer. This reflected his trust in her capacity for self-direction and his role as a facilitator rather than a director of her process.

Gloria’s Struggle With Honesty and Self-Acceptance

Gloria’s struggle illustrates several key themes in client-centered therapy.

She feels guilty about lying to her daughter and fears disapproval. Her conflict about her sex life shows a discrepancy between her perceived self (“sweet and motherly”) and her actual experiences and desires.

This aligns with the client-centered concept of incongruence, where a person’s self-concept is not aligned with their experience.

She wants her daughter to accept her “shady side.” She also wants to feel “right about me” even when her actions go against her upbringing. This underscores unconditional positive regard and self-acceptance.

She longs to be loved “as an imperfect person.” She realizes that love based on a “false picture” is ultimately unfulfilling. Both resonate with the client-centered emphasis on genuine relationship and the pursuit of wholeness and self-approval.

Rogers’ approach of providing a safe and accepting environment, reflecting her feelings, and trusting her inner capacity is designed to facilitate her movement towards greater self-acceptance and congruence.

Innovative Moments: Tracking Change in the Gloria Films

Innovative moments (IMs) deviate from a client’s problematic self-narrative.

They are thoughts, feelings, events, or intentions in the client’s discourse that challenge that narrative.

This narrative perspective views change in psychotherapy as the gradual emergence of small novelties that work against the established, often negative, story the client tells about themselves.

The Innovative Moments Coding System (IMCS) identifies and categorizes these moments in therapy sessions. It sorts them into five types:

• Action
• Reflection
• Protest
• Reconceptualization
• Performing change

Researchers analyze the themes and proportion of IMs across sessions. This shows how a client’s narrative is shifting and developing, even within a single session, and gives insight into the process of therapeutic innovation.

Innovative Moments Across Rogers, Perls, and Ellis

Research using the Innovative Moments Coding System on the Gloria Films revealed differences in the types and themes of innovative moments across the three therapists.

Therapist	Pattern of innovative moments	Main themes
Rogers	Greater diversity of disclosed problems and themes, with a higher proportion of reflection IMs	Clarifying what to do regarding her daughter, feeling right about herself, accepting herself, and asserting herself
Perls	A high proportion of protest IMs, often in response to Perls’ challenging approach	Defending herself and assertiveness
Ellis	The least innovation overall, with a single protest IM related to her feelings of inadequacy in relationships with men	Self-confidence, emerging mainly in reflection

These differences align with the distinct theoretical orientations and therapeutic styles of each therapist.

Practical Applications

Person-centered therapy can help people who want to improve their self-confidence, develop a stronger sense of identity, and cultivate greater authenticity in their lives.

It tends to suit people in these situations:

• Relationships and Decisions: Those seeking better relationships and greater trust in their own judgment and decision-making.
• Broad Difficulties: The evidence is strongest for broad distress, identity and relationship difficulties with no single clearly indicated technique.
• Complex Cases: In more complex or severe cases, it often complements other therapeutic approaches to enhance overall effectiveness.
• Motivated Clients: It is most effective with clients who are motivated, proactive, and willing to engage actively in their therapeutic journey.

People also use it for anxiety, depression, and grief because of its emphasis on personal growth and self-awareness. For depression, non-directive supportive therapy beat control conditions but trailed other therapies in the larger analysis (see the Evidence Check below).

Person-centered therapy also has limitations that students should consider critically. The purely non-directive format may not suit every client:

• Structure-Seekers: Some clients prefer a structured or advice-driven process and may feel frustrated if the therapist consistently refrains from giving guidance or solutions.
• Low Initiative: Clients who are very withdrawn, lack motivation, or are in acute crisis might struggle with a format that requires significant client initiative in leading conversations.

Applications Beyond the Therapy Room

The core conditions were not just a therapy technique.

Rogers saw them as a general theory of constructive human relationship. He spent much of his later career applying them outside the consulting room.

Rogers also opened practice to non-medical practitioners. He did this by locating therapeutic skill in personal qualities rather than medical training. That helped counseling grow into an independent profession across education, health, social work and industry.

Education: Student-Centered Learning

In Freedom to Learn, Rogers (1969) took the core conditions into the classroom. A teacher who is genuine with students, prizes them unconditionally and understands their experience empathically, he argued, creates the conditions for self-directed, significant learning.

A therapist uses the same logic to foster personal growth. The teacher’s congruence, unconditional positive regard and empathic understanding take the therapist’s place.

Rogers’s “student-centered learning” reframes the teacher’s role. The teacher is no longer an authority who transmits fixed content. Instead, the teacher is a facilitator who creates a climate in which students take responsibility for their own learning.

The approach has influenced adult and higher education. It has also shaped open, discovery-based classroom teaching more broadly, well beyond formal psychotherapy.

Encounter Groups

From the 1960s, Rogers became a central figure in the basic encounter group movement. These were intensive small-group experiences, run over several days. They applied the core conditions used in individual therapy to a group of relative strangers (Rogers, 1970).

The aim was personal growth, honest communication and interpersonal awareness. It was not the treatment of a clinical disorder.

Encounter groups spread widely through education, business and community settings in the 1960s and 1970s. They fed into the broader human-potential movement and into organizational “T-group” (training group) traditions.

Rogers thus extended the person-centered relational model to people who were not clients in any clinical sense at all.

Conflict Resolution: The Rust Workshop

In his final years, Rogers turned to international conflict. His best-documented effort is the 1985 Rust Workshop in Rust, Austria (Rogers, 1986).

Rogers and his facilitation team brought together around fifty senior political, diplomatic and academic figures. The guests included high-level government officials from several Central American countries. Observers came from seventeen nations in all.

The multi-day dialogue concerned the escalating conflicts in Central America.

Rogers did not mediate a negotiated settlement in the conventional diplomatic sense. Instead, the facilitators created a climate of psychological safety. Adversaries could speak and be heard empathically.

The premise was that genuine mutual understanding, not persuasion or compromise brokered by an expert, was the route to reduced hostility.

Rogers extended comparable group facilitation to other divided communities in the years that followed. He was nominated for the Nobel Peace Prize shortly before his death in 1987 in recognition of this work.

Evidence Check: Does the Theory Hold Up?

Verdict: Supported with qualifications.

The best-quality evidence shows that therapist empathy and the closely related therapeutic alliance are moderate correlates of outcome across therapy types. This supports the transtheoretical core of Rogers’s idea. That core idea is that the relationship matters across schools.

Whether a non-directive, technique-free relationship is enough is better answered by trials of non-directive supportive therapy. These beat control conditions but trail other therapies in the larger analysis.

Does Therapist Empathy Predict Outcome Across Therapies?

Level of evidence: Meta-analysis or systematic review; not yet replicated.

Rogers’s core conditions are said to be moderate, reliable predictors of outcome across therapeutic orientations. The strongest test is of empathy itself.

• Empathy: Elliott et al. (2018) pooled 82 independent samples and 6,138 clients. The mean weighted r was .28 (95% CI .23 to .33; equivalent to d = .58).
• Alliance: Flückiger et al. (2018) pooled 295 studies and more than 30,000 patients. In face-to-face therapy, r = .278 (95% CI .256 to .299).

In Elliott et al. (2018), between-groups Q = 1.41 (df = 3), so theoretical orientation did not significantly moderate the association. A purely technique-driven account predicts that it would. It did not.

In Flückiger et al. (2018), 2% of effects were negative. But the alliance is a neighboring construct, not empathy. It supports the claim only by inference.

Empathy is therefore a reliable but moderate correlate of outcome across orientations. Both designs are correlational. Neither shows that empathy causes improvement.

Elliott et al. (2018) is the more trustworthy work because it tests empathy itself and reports its own bias checks. Heterogeneity was large (I-squared = 72%). Its authors note that unpublished dissertations were excluded, so publication bias cannot be fully evaluated.

Is a Non-Directive Relationship Enough on Its Own?

Level of evidence: Meta-analysis or systematic review; not yet replicated.

Rogers (1957) held that the relationship itself is the engine of change. Constructive change follows when the conditions are supplied. Trials of non-directive supportive therapy for depression test this idea indirectly.

Cuijpers et al. (2024) pooled 48 randomized trials (5,075 participants) of non-directive supportive therapy for adult depression. The comparison group matters a great deal.

• Against Control Conditions: g = 0.53 (95% CI 0.34 to 0.72; 20 comparisons).
• Against Other Therapies: g = −0.21 (95% CI −0.31 to −0.11; 49 comparisons).
• When Not the Control Arm: g = −0.05 (95% CI −0.17 to 0.07; 14 comparisons).

Cuijpers et al. (2021) ran a network meta-analysis of 331 randomized trials (34,285 patients), of which 42 (12.7%) tested non-directive supportive counseling. That design compares many treatments at once.

Supportive counseling was less efficacious than all other therapies (odds ratios 0.49 to 0.65). It was also not more efficacious than pill placebo.

In the low-risk-of-bias analysis, it was neither significantly worse than most other therapies nor significantly better than care-as-usual or waiting list.

The one direct randomized comparison with a person-centered therapy is Barkham et al. (2021). It was a pragmatic non-inferiority trial. The setting was an English primary-care psychological therapies service.

In total, 510 adults with moderate or severe depression were randomly assigned to person-centered experiential therapy (n=254) or cognitive behavioral therapy (n=256). Outcome assessors were masked.

• Six Months: Person-centered experiential therapy was non-inferior on the PHQ-9 (adjusted mean difference −0.35, 95% CI −1.53 to 0.84; margin 2 points set in advance).
• 12 Months: The difference favored CBT (1.73, 95% CI 0.26 to 3.19), exceeding the margin.

A benefit over waiting list and care-as-usual fits Rogers’s claim. But it also fits any account that credits non-specific factors, so it cannot tell them apart.

Against pill placebo, the comparison that could, supportive counseling was not more efficacious.

The deficit against other therapies counts against sufficiency. Yet in low-risk-of-bias trials, both that deficit and the advantage over control conditions lost significance.

Barkham et al. (2021) suggests the benefit is real but possibly less durable. The result is contested rather than a refutation.

Two cautions apply. Both Cuijpers reviews share authors and draw on the same trial database, so they are one body of evidence.

They also warn that supportive therapy is often a comparison arm that may be delivered as an “intent-to-fail” treatment. It is supportive counseling, not a faithful Rogerian therapy.

A current account should say that non-directive supportive therapy for depression outperforms control conditions but is less effective than other therapies in the larger analysis. A direct trial found person-centered experiential therapy non-inferior to CBT at six months but not at 12.

The six conditions themselves have not been tested as a set in the reviews weighed here.

Critical Evaluation

Strengths

1. Emphasis on Empathy and Understanding

   • Client-centered therapy centers on the therapeutic relationship, particularly the counselor’s ability to empathize with clients.

   • This empathetic stance helps clients feel accepted, understood, and less alone with their problems.

2. Promotion of Self-Direction and Empowerment

   • By not directing or controlling the client, the therapist supports the client’s autonomy and encourages personal growth.

   • Clients often develop greater self-esteem as they experience themselves as the source of change.

3. Focus on the Whole Person

   • This therapy recognizes the complexities of human experience rather than isolating symptoms.

   • It acknowledges that emotional, psychological, and interpersonal well-being are intertwined.

4. Non-Pathologizing Approach

   • Person-centered therapy avoids labeling clients with diagnoses or reducing them to a set of symptoms.

   • This approach can be especially helpful for those who feel stigmatized by traditional mental health systems.

5. Formation of a Genuine, Collaborative Relationship

   • The therapist is encouraged to be genuine (congruent) and transparent, which can facilitate trust.

   • The focus on unconditional positive regard can lead clients to feel emotionally safe and open during therapy sessions.

6. Rigorous Research Tradition

   • At a time when most schools relied on clinical impression alone, Rogers used Q-sort methodology and observer rating scales to make his own claims falsifiable.

   • This was an unusually scientific commitment for a humanistic theorist.

7. Wide and Durable Influence

   • Rogers tested his theory and carried it into education, encounter groups and conflict resolution, giving the approach unusually broad influence for its modest technical apparatus.

   • By locating therapeutic skill in personal qualities rather than medical credentials, it widened access to psychological help.

Limitations

1. Less Structured Framework

   • The non-directive stance means the therapist does not generally offer explicit advice, techniques, or interventions.

   • Some clients may find this too unstructured, preferring more guidance in solving concrete problems.

2. May Not Address Specific Clinical Symptoms Directly

   • For certain psychological issues (e.g., severe anxiety, depression, trauma), a more targeted or integrated approach (e.g., cognitive-behavioral or specialized trauma therapies) can be beneficial.

   • Client-centered therapy sometimes lacks specific techniques to manage or reduce acute symptoms.

3. Therapist Skill and Personal Qualities Are Crucial

   • The success of client-centered therapy hinges on the therapist’s ability to offer genuine empathy, congruence, and unconditional positive regard.

   • If these core conditions are absent or only partially present, the therapy can be less effective.

4. Potential for Slow Progress

   • Since it relies heavily on the client’s own pace and agenda, therapy can take time before noticeable change occurs.

   • Clients in crisis or in need of immediate support might require more directive forms of therapy.

5. Cultural Considerations

   • In some cultural contexts, a “warm, accepting” approach without explicit direction or advice might seem unfamiliar or even uncomfortable.

   • Clients from certain cultural backgrounds might expect a more authoritative or solution-focused role from the therapist.

6. Sufficiency Not Supported

   • Contemporary meta-analyses support the conditions as necessary and facilitative, with moderate effects (around r = .28), but not as always sufficient.

   • Structured, technique-driven approaches often outperform a purely relational approach for narrowly defined problems such as specific phobias, OCD and PTSD (Wampold & Imel, 2015).

7. Congruence and Acceptance Can Conflict

   • A therapist cannot always be fully honest about their reaction to a client (congruence) while withholding all judgment of what the client has just done (unconditional positive regard).

   • Rogers’s writing does not fully resolve how a therapist should hold both at once under pressure.

8. Hard-to-Test Personality Theory

   • The underlying personality theory describes rather than explains why some people move toward growth and others do not.

   • The actualizing tendency, the “fully functioning person” and “the good life” as a direction rather than a state are harder to test than the therapeutic hypothesis built on them.

Contemporary Research

Two recent studies show how Rogers’s relational conditions work inside emotion-focused therapy, a modern offshoot. The empathy meta-analyses sit in the Evidence Check above.

Nødtvedt et al. (2019) interviewed 18 clients after a clinical trial of time-limited emotion-focused therapy for depression, anxiety and severe self-criticism. They identified four themes.

Clients described the therapist’s genuineness and the establishment of trust as important preconditions for opening up to painful feelings and engaging fully in the specific interventions. They also flagged alliance ruptures that need repair.

This is interview evidence from one trial. It illustrates how congruence is experienced but does not test whether it causes change.

Wang et al. (2026) reviewed emotion-focused therapy for self-criticism. This version adds a technique (two-chair dialogue) on top of the relational conditions.

Their systematic review and meta-analysis pooled seven randomized trials and four single-group pre-post studies (531 participants, 87% women).

The trials showed a pooled between-group effect of Hedges’ g = −0.73, a standardized effect size. The authors call this preliminary evidence. Five of the seven trials came from two research teams.

Neurobiological Perspectives

Person-centered theory was built on subjective experience and observed relational behavior, not brain mechanisms. Rogers made no neuroscientific claims. Modern neuroscience has, however, mapped some processes that plausibly underlie empathic understanding.

Decety and Jackson (2004) reviewed the “functional architecture” of empathy. They distinguished at least three component processes:

• Affective Sharing: Sharing the other person’s emotional state.
• Self-Other Distinction: Keeping one’s own perspective separate from the other’s.
• Perspective-Taking: A more deliberate capacity to take the other’s point of view.

This maps loosely onto Rogers’s insistence that empathy means sensing another’s world “as if” it were one’s own, without ever losing the “as if” quality. The decomposition was not derived from Rogerian theory.

The convergence is suggestive, not confirmatory. It shows that Rogers’s description of empathic understanding maps onto processes that neuroscience treats as real and separable. It does not show that person-centered therapy changes brain function in any verified way.

Contemporary Branches

Various contemporary offshoots have developed, guided by different Rogerian principles:

Offshoot	Key figures	Core idea
Child-centered play therapy	Virginia Axline, Garry Landreth	Applies the nondirective principle to therapy with children, using play as their natural mode of expression. It believes in the child’s capacity for inner growth and healing through play and creativity in an accepting relationship.
Focusing-oriented psychotherapy	Eugene Gendlin	Sees experiencing as central to growth. It gently guides clients to bring awareness to their bodily “felt senses” to get in touch with unclear feelings that can carry forward change if articulated.
Emotion-focused therapy	Leslie Greenberg	Integrates person-centered principles with Gestalt therapy and contemporary emotion research. It sees problematic emotion schemes as causing disturbances, which can be worked through and transformed in the therapeutic alliance (the collaborative bond between therapist and client) via emotional processing tasks.
Dialogical and relational approaches	Inspired by Martin Buber	Emphasize the two-way, co-created therapist-client encounter as central. Inspired by Buber’s “I-Thou” concept, the client is seen as infinitely foreign but can be related to openly, with flexibility beyond just empathy.
Creative person-centered approaches	Natalie Rogers	Use arts, movement, music, and other creative modalities to facilitate self-discovery and spontaneous expression within a nondirective relationship. Creative processes are seen as actualizing growth pathways.
Pre-therapy	Garry Prouty	For clients with severe contact impairments. It uses very concrete mirroring and repetitions of client behavior to gently try to reestablish psychological contact as a precursor to therapy.
Integrative person-centered approaches	Mick Cooper and John McLeod (pluralistic therapy)	Combine the core conditions with other practices, challenging “purism” and recognizing that different clients need different things. Pluralistic therapy is one prominent integrative framework, emphasizing client preferences.

Person-Centered Training and Supervision

In training and supervision, the focus is on using person-centered relating to stimulate trainee/therapist personal growth and self-understanding.

The assumption is that their own actualization will transfer to more effective practice.

Training:

• Belief that trainees have inherent capacity for professional development. Allows programs to be highly self-directed – trainees shape curriculum, assessments etc.
• With less didactic input, focus is instead on experiential learning to catalyze growth:
  • Personal development groups
  • Encounter groups
  • Skills practice sessions
• Feedback centers on helping develop empathy/acceptance capacities and active listening skills.

Supervision:

• Primary aim is to facilitate therapist self-awareness and congruence.
• Supervisor takes exploratory, person-centered style rather than authority role.
• Discussion explores supervisee’s experiences/reactions to client to reveal material at the “edge of awareness.”
• Audio recordings of sessions often used to understand relational dynamics.
• Supervisory relationship itself models acceptance.

Why Person-Centred Therapy?

Rogers strongly believed that therapists should be warm, genuine, and understanding for a client’s condition to improve. 

The starting point of the Rogerian approach to counseling and psychotherapy is best stated by Rogers himself:

“It is that the individual has within himself or herself vast resources for self-understanding, for altering his or her self-concept, attitudes and self-directed behavior – and that these resources can be tapped if only a definable climate of facilitative psychological attitudes can be provided” (Rogers, 1980, pp. 115-117).

Perception and Self-Healing

Rogers (1961) rejected the deterministic nature of both psychoanalysis and behaviorism. He maintained that we behave as we do because of the way we perceive our situation. “As no one else can know how we perceive, we are the best experts on ourselves.”

Rogers believed theory should come out of practice. He developed his theory from his work with emotionally troubled people.

He claimed that we have a remarkable capacity for self-healing and personal growth, leading towards self-actualization. He emphasized the person’s current perception and how we live in the here and now.

Rogers noticed that people describe experience in terms of themselves. Examples are “I don’t understand what’s happening” or “I feel different to how I used to feel.”

Self-Concept and Self-Esteem

Central to Rogers’s (1959) theory is the notion of self. The self-concept is defined as “the organized, consistent set of perceptions and beliefs about oneself.”

It consists of all the ideas and values that characterize “I” and “me”. It includes perception and valuing of “what I am” and “what I can do.”

The self-concept is therefore central to our total experience. It influences both our perception of the world and our perception of ourselves.

For instance, a woman who perceives herself as strong may behave with confidence. She sees her actions as those of someone confident.

The self-concept does not always fit with reality, though. How we see ourselves may differ greatly from how others see us.

For example, a person might be very interesting to others and yet consider himself to be boring. He judges and evaluates this image he has of himself as a bore, and this value will be reflected in his self-esteem.

The confident woman may have high self-esteem. The man who sees himself as a bore may have low self-esteem, presuming that strength and confidence are highly valued and that being boring is not.

References

Barkham, M., Saxon, D., Hardy, G. E., Bradburn, M., Galloway, D., Wickramasekera, N., Keetharuth, A. D., Bower, P., King, M., Elliott, R., Gabriel, L., Kellett, S., Shaw, S., Wilkinson, T., Connell, J., Harrison, P., Ardern, K., Bishop-Edwards, L., Ashley, K., . . . Brazier, J. (2021). Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): A pragmatic, randomised, non-inferiority trial. The Lancet Psychiatry, 8(6), 487–499. https://doi.org/10.1016/S2215-0366(21)00083-3

Cuijpers, P., Miguel, C., Ciharova, M., Harrer, M., & Karyotaki, E. (2024). Non-directive supportive therapy for depression: A meta-analytic review. Journal of Affective Disorders, 349, 452–461. https://doi.org/10.1016/j.jad.2024.01.073

Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I. A., & Furukawa, T. A. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20(2), 283–293. https://doi.org/10.1002/wps.20860

Decety, J., & Jackson, P. L. (2004). The functional architecture of human empathy. Behavioral and Cognitive Neuroscience Reviews, 3(2), 71–100. https://doi.org/10.1177/1534582304267187

Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399–410. https://doi.org/10.1037/pst0000175

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172

Mearns, P., & Thorne, B. (1988). Person-Centred Counselling in Action (Counselling in Action series). London: SAGE Publications Ltd.

Nødtvedt, Ø. O., Binder, P.-E., Stige, S. H., Schanche, E., Stiegler, J. R., & Hjeltnes, A. (2019). “You feel they have a heart and are not afraid to show it”: Exploring how clients experience the therapeutic relationship in emotion-focused therapy. Frontiers in Psychology, 10, Article 1996. https://doi.org/10.3389/fpsyg.2019.01996

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