3V\FKRORJLFD Eelen, P., et al. (2018). The Therapist as Conditioned Stimulus. Psychologica Belgica, 58(1), ψ %HOJLFD pp. 172–183, DOI: https://doi.org/10.5334/pb.454

THEORETICAL-REVIEW ARTICLE The Therapist as Conditioned Stimulus Paul Eelen, Eric Depreeuw and Omer Van Den Bergh

This manuscript is part of a special issue to commemorate professor Paul Eelen, who passed away on August 21, 2016. Paul was a clinically oriented scientist, for whom learning principles (Pavlovian or operant) were more than salivary responses and lever presses. His expertise in learning psychology and his enthusiasm to ­translate this knowledge to clinical practice inspired many inside and outside aca- demia. Several of his original writings were in the Dutch language. Instead of editing a special issue with contributions of colleagues and friends, we decided to translate a selection of his manuscripts to English to allow wide access to his original insights and opinions. Even though the manuscripts were written more than two decades ago, their content is surprisingly contemporary. This manuscript was originally published in 1989 as part of an edited book on the therapeutic relation. In this chapter, Paul Eelen takes a critical position against the domi- nance of the client-centered approach. He presents the therapeutic relation as a behavioural interaction between the patient and his therapist which is subject to laws of learning. This is exemplified by an in-depth analysis of the therapist as a conditioned stimulus. First published as: Eelen, P., Depreeuw, E., & Van den Bergh, O. (1989). De ­therapeut als geconditioneerde stimulus. In H. Vertommen, G. Cluckers, & G. Lietaer (Eds.), De relatie in therapie (pp. 147–165). Leuven: Universitaire Pers Leuven.1

Keywords: therapeutic relationship; empathy; learning principles

Although these are times of therapeutic ecu- great departure point for such an exercise.2 menism, it is appropriate to reflect, from Hence the slightly provocative title! To label time to time, on what distinguishes existing the therapist a conditioned stimulus at first therapeutic methods. A reflection on the glance appears to be fairly at odds with the contrast between behaviour therapy and conceptual framework in which the T-C rela- client-centered therapy seems in order, given tionship is described from a client-centered the context in which the idea for this book therapy perspective. This aptly summarises was shaped. The therapist-client (T-C) rela- the two-part focus of this contribution. The tionship, the subject of this book, offers a first paragraph explains why behaviour ther- apists remain slightly hesitant to accept the basic philosophy underlying client-centered Faculty of Psychology and Educational Sciences, therapy. The second paragraph discusses how KU Leuven, BE the T-C relationship can be situated in a con- Corresponding authors: Paul Eelen ([email protected]), Omer Van Den Bergh ceptual framework from a behaviour therapy ([email protected]) perspective. Eelen et al: The Therapist as Conditioned Stimulus 173

The genuine, unconditional and and sufficient conditions that researchers and emphatic therapist therapists had been searching for since many Naturally, the critical observations contained years (and, Rogers’ article notwithstanding, in this paragraph might be focused on a are still fruitlessly searching for to this date). “straw man” rather than on what really hap- Six conditions are necessary in Roger’s pens in client-centered therapy. We know view: (a) there needs to be a psychological from experience that statements about relationship between two persons, (b) with behaviour therapy made by other disciplines, one of these two (the client) experiencing often seem unrecognisable. We, in turn, run a state of incongruence, and the other (the that same risk in this outsider position. We therapist) demonstrating the core conditions take consolation in the fact that “the insid- of (c) genuineness (congruence), (d) uncondi- ers” will know better! tional positive regard and (e) empathy, that of Still, these critical observations seem jus- course (f) also have to be perceived by the cli- tified because, all too often, the opinion ent as such. When these conditions are met is expressed that client-centered therapy during therapy, they are also sufficient to includes the so-called “core conditions” that bring about a change process in the client. every therapist, no matter what school, should Rogers was surprised by the “simplicity have received training in. True ecumenism, of what has emerged” (p. 45); he was even then, appears to lie in the teaching of rela- more surprised when he realised that, at first tional skills through client-centered therapy glance, so many elements were not included and “technical expertise” through behaviour as necessary and sufficient that were always therapy. This reasoning is even somewhat the mentioned as important in the then existing basis for the training programme for clinical literature. These conditions are considered psychologists in Leuven today. necessary and sufficient (a) irrespective of As far as we are concerned, this is a mis- the client’s problem, (b) irrespective of the placed ecumenical movement because the dif- therapeutic orientation one adheres to, (c) ferences between the approaches are still too irrespective of the therapeutic setting, (d) large to treat them as one. That, at least, is the irrespective of one’s professional training impression we have after having browsed the and (e) with no need of assessment. literature on client-centered therapy. What The author’s name, the chosen title and its is striking from our reading of this literature presentation as a series of hypotheses made is (a) the poor operationalisation of the key this article a milestone in the evolution of concepts, which probably stems from matters client-centered therapy. The author’s name of principle rather than technical reasons; (b) guaranteed that its contents were based on the limited reference to more general psycho- a contemplation on years of therapeutic logical concepts; and (c) that the concepts practice. Had the same article been written of “experience” and “behaviour” have been by a novice therapist, it would have barely disconnected. Each of these observations been considered suitable for publication and is discussed below, taking into account the it certainly would not have had the same abovementioned outsider position. influence. The title held quite a few scien- First, there is the poor operationalisation of tific promises. Every empirical science after the central concepts, particularly with respect all aims to explain a phenomenon (in this to the therapist’s so-called “core conditions”. case, the change in the client) by describing Carl Rogers must have been in a very opti- its sufficient and ideally also its necessary mistic state of mind when, in 1957, he pub- conditions. Using logic notation from phi- lished an article with the promising title losophy of science, this is represented as: if The Necessary and Sufficient Conditions of p then q and if q then p, or p ⇔ q. But this Therapeutic Personality Change. On eight presupposes that both p and q can be objec- pages, a summary is offered of the necessary tified in an unambiguous fashion. 174 Eelen et al: The Therapist as Conditioned Stimulus

And this is where the trouble lies. Rogers in the therapist; however, concrete (verbal himself admits in the article that such an and non-verbal) behaviour rather than an operationalisation of both the conditions inner core condition is observed. (p) and the change process in the client (q) In short, what Rogers and many research- is largely absent today. Still in the same opti- ers in client-centered therapy later labelled as mistic mood, he nonetheless offers a design “therapeutic factors” are not factors but con- for what such measurements might look like, sequences of certain, insufficiently explained even though his suggestions remain limited factors. To refer back to the abovementioned to the listing of items in a questionnaire. symbols: they are qs of which the ps remain More sophisticated measurement unclear. The extensive research that Rogers’ ­instruments today exist to assess Rogers’ article inspired, remained primarily correla- statements. Irrespective of the result of this tional in nature; it ultimately yielded a poor research, the operationalisation of these nec- crop (Lietaer, 1983). One of the reasons for essary and sufficient conditions nevertheless this poor crop, according to Lietaer, is proba- remains problematic – due to principal more bly the fact that client-centered research was than technical reasons. On the one hand, too reductionist. In our opinion, the reason painstaking attempts are made to avoid is in fact precisely the opposite: the research translating these conditions into objective and the research question was not reduction- criteria. Whereas Rogers’ initial emphasis ist enough. Humanistic psychology in gen- (1951) was on the technical aspects (what eral and client-centered therapy in particular should you do so that empathy, genuine- appears to want to avoid every form of reduc- ness etc. are expressed in the T-C relation), he tionism, which threatens to snuff out every- gradually and increasingly moved away from thing scientific about it. After all, science by this: to be rather than to do is what matters. definition reduces the overall experience. At stake are the therapist’s internal positions We here arrive at an issue that remains that will (spontaneously?) be expressed and characteristic for the further evolution of externalised as a result, possibly in a very client-centered therapy, namely the limited ­idiosyncratic fashion. reference to more general psychology litera- ture. This unjustifiably perpetuates the gap The externalisation, the communica- between psycho-therapy and psycho-logy. tion of empathy is not what is most Rogers views a training in psychology neither ­important to me: the inner empathic as a sufficient nor as necessary condition to experience is what is fundamental and the development of a helping relationship. it is the source itself for the therapeu- Anyone who is involved in a psychotherapy tic activity. I feel at my best when the training programme will subscribe to this expression of my empathy occurs natu- view. By analogy, one could state that one rally – when it doesn’t require me to does not need pedagogical training to be a think, to ask questions, to purposefully good father or mother. But unlike parent- intervene in particular ways. (­Rombauts, hood, psychotherapy concerns the exercise 1984, p. 173, our translation) of a profession that can and should require a certain level of expertise that exceeds the On the other hand, it is assumed that these above-described core conditions and that core conditions nonetheless are objectifi- should have as its foundation a thorough able since external evaluators are assumed to training in what psychology has accrued in evaluate them through the measuring scales scientific knowledge. This knowledge then, is that have been designed for this purpose. It indeed not a sufficient and necessary condi- is moreover assumed – and this was one of tion to help a fellow human; it is, however, the necessary conditions for Rogers – that a necessary condition to be able to position the client can perceive these core conditions oneself as an expert. It is not just advisable Eelen et al: The Therapist as Conditioned Stimulus 175 that we have this knowledge at the back of to the latter). However, the theoretical foun- our mind when someone approaches us for dation used to support this contrast appears professional help; it is our duty. to be rather weak, unless one continues to One of Rogers’ greatest accomplish- unjustifiably identify behaviour therapy ments remains that he called the exclusive with orthodox behaviourism à la Watson. expertise of psychiatrists in the practise of We are not at all opposed to the claim that psychotherapy into question, and that he what matters in therapy is the client’s lived demanded the right for clinical psycholo- experience, his “felt experience”. But one gists to practise psychotherapy. This should does not have direct access to this experience. not, however, result in a plea that any per- Continuing to believe in this means returning son who is empathic, genuine and accept- to classical introspective psychology. The only ing in their relationship with others should thing one can do is to trace the requirements, be appointed as therapist. Psychotherapy is the conditions (independent variables) that applied psychology and it should ideally be influence this “felt experience” (dependent practised by psychologists. The often limited variable), in a way similar to that of a behav- psychology training of psychiatrists-psycho- iour therapist who does not directly alter the therapists is very regrettable in this regard. behaviour but suggests changes in the ante- It seems to us that client-centered therapy cedent or consequent factors that determine has not sufficiently emphasised this neces- the behaviour. This experimental concep- sity of embedding therapeutic practice in sci- tual model is the core nature of behaviour entific knowledge and that it has, as a result, therapy, which in turn causes it to remain often provided a breeding ground for train- at odds with the fundamental philosophy of ing institutes that regard the basic psychol- ­client-centered therapy. ogy training of participants as of secondary importance. It is for instance notable that The Therapist as a Conditioned Gendlin’s (1981) work on focusing does not Stimulus make a single reference to the comprehen- Technique Versus Relationship? sive psychology theories on emotion and Behaviour therapy is often criticised for not affect. The exceptions to this rule confirm it. paying attention to the T-C relationship and There was, for instance, a great deal of affinity for even denying its significance. Such criti- between (cognitive) behaviour therapy and cisms are partly unfounded. Although behav- Wexler and Rice’s attempt (1974) to describe iour therapy has demystified the importance client-centered therapy within the frame- of the T-C relationship to a certain degree work of information-processing theories. This (Walker et al., 1981), it is not a topic that has attempt, however, has not always been met not at all been discussed (for multiple over- with the approval of insiders (De Haas, 1984). views, see Wilson & Evans, 1977; De Voge & A similar affinity exists with Greenberg and Beck, 1978; Sweet, 1984; Hoorens, 1986). Safran’s work (1987) on emotion. As such On the other hand, it cannot be denied that attempts also start to pave the way for an the conceptualisation of this T-C relationship increasingly mutual conceptual framework has remained largely absent. The T-C relation- and uniform research strategies, a certain ship is considered the frame in which the level of ecumenical movement appears to actual procedures for behaviour change, the become both possible and justified. so-called techniques, can be applied. Many Finally, we would like to briefly reflect on even argue that change does not occur inside what is usually cited as the main difference but outside therapy. At its most extreme, between client-centered therapy and behav- therapy is then reduced to the assigning and iour therapy. One approach is supposed to pri- correcting of homework. Upon closer inves- marily focus its attention on the “experience” of tigation, this division between “relationship” the client, while the other engages with behav- and “techniques” appears to be artificial as iour (with the epithet “merely” usually added the technique in many ways is built into the 176 Eelen et al: The Therapist as Conditioned Stimulus relationship and the other way around. This So how can one then sensibly discuss the artificial aspect is present in the (limited) relationship from a learning model? research that has been conducted from a behaviour therapy angle so as to distil the The T-C relationship and the Operant influence of the relationship versus the tech- Learning Model nique. This research unjustly mirrors itself to Several studies were completed in the fifties­ the “pills research” that has been conducted and sixties of the 20th century from the in medicine. For instance, attempts have been operant learning model under the banner of made to apply the systematic desensitisation “verbal conditioning”, with the therapist (or (SD) technique by means of a computer and experimenter) functioning as a social rein- to then compare these results with those forcer. The most famous of these are probably of SD applied in a T-C relationship (Lang, the “hm-hm” experiments, which systemati- Melamed, & Hart, 1970). Disregarding the cally influenced a test subject’s verbal behav- results of this research for a second allows us iour in terms of contents and form, and this to contemplate the question of whether such in a more experimental context as well as an approach is even capable of offering clari- in the context of a conversation. This was fication regarding the role of the relationship immediately used to demonstrate that such versus the technique. Must we conclude that a directive influence was also present in the the relationship is of no importance or that Rogerian approach that was then still viewed a good relationship with a computer is also as the most non-directive therapy (see, for possible, if a computer and a therapist do just instance Rogers, 1960). In hindsight, the as good a job?3 If the computer very clearly research aims and questions of these stud- does not do as well – and let us assume this ies often come across as somewhat naïve. for the sake of our profession – does this This was often due to the prior definition of then mean that the relationship is an added a social reinforcer, which was severed from value to the technique, or that the computer the context in which, the therapist (experi- is not sufficiently capable of applying the menter) through whom, and the client (test technique? A study that applied SD through subject) to whom this reinforcer is admin- both a “cold” and a “warm” therapist appears istered. This was redressed in later studies to have a similarly fuzzy method in our view (for an overview, see De Voge & Beck, 1978). (Morris & Suckerman, 1974a, 1974b). The From a Skinnerian point of view – in which reasoning was the following: the technique a “reinforcer” is always defined in accord- is present in both conditions, but the rela- ance with its effect on the behaviour – such a tionship is added only by the warm therapist. redressal was but appropriate. It is sometimes If, however, a cold therapist, due to prior ­forgotten that Skinner was one of the biggest experiences, evokes so much distrust, resist- promoters of N = 1 research, or the “person- ance and opposition that he is not listened centered” research. to, such a study would not be very different No matter how limited the focus of these from a comparison between SD with instruc- studies was, they succeeded in drawing atten- tions in Chinese (potentially even offered in tion to the fact that a therapist’s verbal and/or a “warm” fashion) and instructions in one’s non-verbal behaviour has a strong influence native language. on the client’s behaviour. Something that In short, we do not think it is fruitful to appears to be self-evident at first; yet how view the relationship only as the framework often is this influence not underestimated, in which the actual therapeutic techniques also outside the context of therapy? can be applied. To ask whether a therapeutic These studies approached the relation- effect must be ascribed to a technique or to a ship from one viewpoint only: the influ- relationship is to ask an impossible question ence of the therapist (or experimenter) on as “the relationship” is a too multi-faceted the client (participant). The research ques- concept to offer a decisive answer. tion only becomes truly relational when Eelen et al: The Therapist as Conditioned Stimulus 177 the interactional element is addressed. Like use the example of the rat cartoon: the rats in the famous cartoon of two rats in the might think that they have conditioned Skinner box, with one rat saying to the other: the test leader, but the latter knows better! “Look what a good job I did of condition- Directing here means knowing which way to ing that researcher: when I push the lever, go, formulating an objective. This is precisely he gives me food!”. Obviously, something where behaviour therapy does not fall short. similar occurs in therapy: the therapist influ- Explicitly discussing the objective with the ences the client, but the latter in turn also client does not imply that the means of arriv- influences the therapist. In more recent lit- ing at that objective are fully made explicit. erature, we can see the gradual development Just as an experimenter does not fully inform of more established research methods that his participant about the study’s independ- aim to get a grip on this process of mutual ent variable, a therapist similarly should not influence. Particularly, methodologies such make his method all too transparent. This of as sequential analyses are increasingly being course constitutes a sort of manipulation – applied in the different therapy orientations, that most feared and pejorative term among although the unit of analysis is often defined therapists – but the question is whether we in very different ways (Russell & Trull, 1986; can eventually escape from it. Ever since Revensdorf et al., 1984; Schindler, 1988). Skinner’s and Rogers’ historic debate, this Whether these new methodologies offer a theme has often resurfaced in the literature valuable contribution remains to be seen. and much of the criticism directed at behav- Still, they appear to offer an important com- iour therapy is tied to a misunderstanding plement to both questionnaires and the of the notions of control and manipulation. experimental research that is often limited What to think of a client-centered therapist to the manipulation of one aspect. who tells his client in advance: “Look, I’m Similarly promising seems the research going to reflect on your experience every that was inspired by an ethological approach. now and then in the hopes that this will help Consider, for instance, Bouhuys and Van you get deeper into it!” Or consider an ana- den Hoofdakker’s study (1986) on depressed lyst who justifies his impersonal behaviour patients. Non-verbal aspects of the therapist- toward the client by hoping that it will cause client interaction (for instance, eye contact, the client to arrive at a good transfer! hand movements, etc.) are carefully observed We are manipulators after all! The analyst and recorded. It is shown that a prognosis can and the behaviour therapist do this explic- already be made regarding a therapy’s success- itly; the client-centered therapists deny it, fulness, based on this non-verbal behaviour in but they do it too. As soon as a therapist the first conversation. This type of study is of starts justifying his method either to himself course difficult to perform in a normal prac- or to his supervisors with “I’m doing this to tice setting. It does, however, make us sensi- …” (and he hopefully has such justification), tive to the variables that are otherwise seldom he becomes a manipulator, a practitioner. made explicit. And is this not – at the end of the day – the purpose of research? The T-C Relationship and the Pavlovian Both the sequential analysis and the eth- Learning Model ological approach do not have a specific The conceptual framework of the oper- behaviour therapeutic focus, but they are ant learning paradigm does not suffice to compatible with it because they fully sub- describe the core of a T-C relationship. It scribe to a functionally experimental concep- does not, after all, in itself offer an answer tual framework. to the question of why precisely a therapist No matter how mutual the influence can become an important social reinforcer between T and C, in our opinion, the thera- or, more generally, why the therapist comes pist will have to direct this process. To again to obtain special significance to the client. 178 Eelen et al: The Therapist as Conditioned Stimulus

What, in many cases, makes him an In a “pure” classical conditioning pro- emotionally charged figure for the cli- cedure, these operations are response- ent? Behaviour therapy does not make the independent and usually involve stimulus answer to this question sufficiently explicit. manipulations by the experimenter (or by Wolpe, one of its founding fathers, never- “Mother Nature”). In the operant learning theless offered a first hint by describing the paradigm, these operations can be viewed as therapist as an “inhibitory stimulus”. This the outcome, the result of a behaviour in the leads us to the terminology of classical or operant learning paradigm. Pavlovian conditioning. It scarcely deserves Classical conditioning at its essence simply mention that this learning paradigm, pos- means that (neutral) stimuli are contingent sibly even more so than the operant model, on one of the six possible operations, which has fallen victim to caricatural depictions causes them to acquire a different mean- that are true travesties. Even behaviour ing. We can also generally describe this new therapists today comment on it with scorn, meaning as “pleasant” or “unpleasant”. especially now that cognitive behaviour It is, however, possible to further slightly therapy has offered them a more modern differentiate this dichotomous categorisa- jargon. This chapter of course is not the tion of pleasant-unpleasant by ascribing a place to redress these caricatural depictions particular affective and emotional meaning (for a more elaborate discussion, see Eelen to each of these operations (see, for instance: et al., 1988). Still, it is useful to first shed Mowrer, 1960; Gray, 1975, 1987; Bakker-De light on the essence of this paradigm before Pree, 1987). The absence of a positive stimu- applying it to the T-C relationship. lus, for instance, evokes frustration (anger), the administration of a negative stimulus fear, A number of key thoughts on and the removal of a positive stimulus disap- classical conditioning pointment. These three affective states can Classical conditioning is a process through summarily be described as “negative feelings”. which stimuli (CS; conditioned stimuli) When a negative stimulus fails to appear, (­persons, situations, events) acquire a new safety is provided; the administration of a posi- meaning because they are contingent on tive stimulus provides hope and joy; the removal what happens to a stimulus (UCS; uncondi- of a negative stimulus relief. This produces tioned stimulus) (person, situation, event) three separate types of “positive feelings”.5 that already has a well-defined meaning.4 It is remarkable then that classical condi- For the purpose of this discussion, we tioning has almost always been identified limit this clearly defined meaning to the with the change in meaning associated with affective, emotional dimensions of these neutral stimuli that are contingent on the stimuli, which we roughly define into two administration of a UCS. Familiar prototypes categories – “pleasant” and “unpleasant”. include “Pavlov’s dog”: an auditory or visual What now can happen to these stimuli? stimulus that is followed by food receives We distinguish between three operations: (a) a positive valence, while a neutral stimu- a meaningful stimulus can be administered; lus that is followed by an aversive stimulus (b) this stimulus can be removed; (c) this acquires a negative valence. The procedures stimulus does not occur, even though it is of what Pavlov dubbed excitatory condition- expected. A learning process, in other words, ing are sufficiently well-known. always precedes the latter operation: noth- The other operations indicating inhibitory ing only becomes something when a certain conditioning, however, are just as important expectation has been created in advance. (and they were also to Pavlov). The absence The UCS nature (pleasant – unpleasant) of an expected stimulus, especially, has griev- and the three types of operations can be ously been overlooked. For the purposes of combined into six possible operations. clarification, we offer a summary description Eelen et al: The Therapist as Conditioned Stimulus 179 of the prototypical procedure developed by conditioning and relate it to the T-C relation- Pavlov himself to realise conditioned inhi- ship, we wish to offer a brief justification for bition. Consider, for instance, a situation why we believe these conditioning phenom- in which stimulus A is always followed by a ena are relevant for general clinical practice. UCS. Stimulus A thus gradually induces the In the previous pages, we have often used expectation that the UCS will be adminis- terms as “meaning” and “expectation” when tered (excitatory conditioning). Every now such terms at first glance appear to con- and again, A is administered together with trast with the language traditionally used a different neutral stimulus B, and A + B is to discuss conditioning. What makes condi- not followed by the UCS. Under these circum- tioning fascinating, then, is that such terms stances, B becomes an inhibitory stimulus. developed as theoretical constructs from The absence of the UCS administration is as it meticulous observations of the behaviour of were ascribed to stimulus B, which causes B to laboratory animals, whereas clinical practice acquire a meaning that is opposite to that of (as well as behaviour therapy) all too often stimulus A. If stimulus A for instance induces has a tendency to equate these theoretical fear, stimulus B acquires a meaning of safety. constructs with that which a client verbally Although it would be impossible to shed reports from his phenomenal experience. light on all the different facets of inhibitory The danger exists that behaviour therapists conditioning in the context of this paper, we as well will overlook the richness of the con- do briefly want to note inhibitory condition- ditioning model, due to the mushrooming of ing’s role in extinction. Let us again further pseudo-cognitive models. clarify this using a schematic presentation. In a first phase, stimulus A is always followed by Application on the T-C relationship the UCS. After this excitatory conditioning, A Wolpe’s abovementioned hint, which is presented independently, with the UCS no described the therapist as an inhibitory stimu- longer succeeding it. After a while, A again lus, can serve as a point of departure for appli- becomes a neutral stimulus (extinction). Let cation of this conceptual framework to the T-C us now assume that stimulus A is presented relation. Inhibitory conditioning occurs when together with B, a neutral stimulus, from the a UCS is removed or remains absent. In case of extinction phase onward. A + B of course a positive UCS, the neutral contingent stimu- are no longer followed by the UCS. Under lus acquires a “negative” meaning; in case of a these conditions, B becomes an inhibitory negative UCS, the stimulus that is contingent stimulus, and something highly remarkable on its removal or ‘remaining absent’ acquires occurs: extinction at first glance appears to a “positive” meaning. occur when A + B are offered. This extinction, Particularly in a therapeutic setting, these however, is due to the fact that B partially operations can frequently occur. It is con- inhibits the effects of A. As long as both are sequently not surprising that the therapist presented together, extinction appears to be becomes a very ambivalent figure. On the complete. As soon as A is no longer accompa- one hand, he is often likely to be the source nied by B, however, the original conditioning of the removal or absence of a positive stimu- effect is again foregrounded. Recent studies lus: a client who expects his therapist to show have revealed that the role of stimulus B can a great level of intimacy will be inclined to also be assumed by context stimuli. This phe- interpret his therapist’s neutral benevolence nomenon possibly plays an important role in as dismissive. Feelings of resistance and frus- addiction, for which the role of conditioning tration will develop that may even cause him is increasingly becoming the central focus. to end the therapy. Further below we will also discuss the related On the other hand, the therapist is often possibility of therapist-addiction. the source of the removal or absence of neg- Before we conclude this discussion of ative stimuli. Several examples can further the core concepts associated with classical illustrate this. 180 Eelen et al: The Therapist as Conditioned Stimulus

First and foremost, the initial hesitancy to These are just a couple of examples to seek a therapist is still considerably strong illustrate how the therapist can become an in the culture we live in. Most clients have inhibitory stimulus. We would like to relate already gone through arduous ordeals before these examples to a couple of more general they can be persuaded to seek therapy. They considerations. have, in the meantime, developed an expec- First, these examples perhaps illustrate tation pattern for the dismissive manner in that conditioning is not a process that begins which their environment responds to their from a clean sheet. The conditioning process problems and this has caused them to accu- is determined by a client’s entire prior history mulate many frustrations. While the client and of course that of the therapist as well: expects criticism and rejection, both are nor- the client after all often entertains explicit mally absent with a good therapist. as well as implicit expectations vis-à-vis the In addition, it is often the case that a cli- therapist, who in his turn explicitly or implic- ent begins a session in a very negative mood itly responds to these expectations. No matter and feels somewhat relieved at the end. This what the therapist does, his behaviour and his relief – rightly or wrongly – is ascribed to person cannot remain neutral. From a condi- the therapist. tioning perspective, it can even be predicted Finally – and this is probably typical for that such inhibitory conditioning will occur at what happens in behaviour therapy – the its strongest in psycho-analytic settings. Given client often lives in the expectation that he the analyst’s neutral, impersonal attitude, it is can no longer handle certain things. A cli- not surprising that the therapeutic event in ent for instance has come to expect that he the analysis is almost exclusively situated in will always have a panic attack whenever he this relational field; by behaving meaning- visits a supermarket. Together with the ther- less, the analyst becomes a Rorschach packed apist, he is confronted with the situation with meanings, from resistance to transfer. It that he is fearful of (exposure) and there is is not clear to us whether psychoanalysis also no panic attack! At first sight, this appears takes into consideration the inhibitory condi- to be a successful intervention. But there tioning that can be viewed as more or less as is a considerable danger that the absence an opposite transfer.6 of panic is fully ascribed to the therapist’s Inhibitory conditioning is what makes the presence. (This, in fact, is yet another dem- T-C relationship so special – at least to the onstration of the impossibility of separat- clients who enter therapy for a specific prob- ing relations and techniques!) The therapist lem. The therapist to them is often a person becomes the safety signal, which the client who offers them safety, comfort. The “heal- no longer lets go off. ing” aspect of this process cannot be denied. A similar situation occurs when the thera- Still, precisely this has a treacherous effect pist confronts the client with imaginary stim- that can deter rather than promote the cli- uli that elicit heavily charged emotions in the ent’s independence. For the therapist, it is client. Think, for instance, of bereavement after all very reinforcing at first to experi- therapy. At first glance, such an approach ence being that person who offers the client appears to be the ideal situation to make the safety and comfort. The therapist interprets therapist an aversive stimulus. It is precisely what almost seems like a crush on the part this aspect of the procedure, however, that is of the client as rapprochement behaviour, discussed with the client in advance, so that when it is in fact avoidance behaviour. This is the likelihood that the experiencing of nega- how a therapy addiction – or therapist addic- tive emotions is ascribed to the therapist is tion – develops. small. The conditioning effect of the subse- Conditioning literature has shown us that quent emotional relief, which the therapist an inhibitory stimulus only extinguishes when is of course most associated with, often is not there is nothing left to inhibit. And this is discussed in advance. where – from a conditioning perspective – the Eelen et al: The Therapist as Conditioned Stimulus 181 therapist’s almost paradoxical task lies. On now formulate a specific research question the one hand, he is worried about obtaining focused on the influence of a therapist’s an extinction of feelings of fear, aggression presence on a client’s execution­ of a task. or blame by “using techniques”. Because he is In accordance with the above-mentioned himself a central stimulus in this extinction description of a therapist as an inhibitory process, all the requirements for inhibitory stimulus, it is to be expected that his pres- conditioning towards his person are met. This ence will not have a disruptive effect on a in fact causes him to hamper the extinction. ­client’s execution of a task. Successful completion (with the attendant Alternatively, the well-known “priming” risk of failure) of such a paradoxical task paradigm from cognitive psychology might appears to require a clear description from be used. Presenting a stimulus activates an the outset of the T-C relationship as a work- associative network that causes stimuli that ing relationship, a functional relationship, and are related in meaning, to subsequently be putting emphasis on what happens outside processed more easily than unrelated stim- rather than inside the therapy room. uli. This again creates a series of possibilities It should finally be noted that this condi- to find out in which meaning pattern a cli- tioning perspective was not formulated on ent situates his therapist (and perhaps vice the basis of research. It is somewhat surpris- versa), as well as how this meaning pattern ing that an approach that so heavily empha- evolves as a function of therapy progress (for sises the influence of the environment has a broader application of the priming para- performed so little research concerning this digm, see Bower, 1986). T-C relationship. A therapist is after all the What connects these suggestions is their most important stimulus in a therapy context! mutual attempt to identify a therapist’s Useful research could take different direc- meaning to his client in a scientifically sound tions. We already mentioned a number of manner, and this in a more indirect manner research strategies that relate to the therapy than through the use of questionnaires. Such process in itself, a within-session analysis research may strike a veteran clinician as arti- of the therapist-client interaction. The con- ficial. Research, however, does not have as its ditioning framework can help to define the purpose to simulate “reality” as faithfully as functional units. possible, but instead aims to critically ques- We believe it would be similarly useful, tion our vocabulary of concepts, and such and perhaps conceptually clearer, to perform critical questioning should ideally take place research that uses existing experimental par- in a controlled experimental setting. adigms that have both a methodological and theoretical foundation as a starting point for Conclusion a study of the T-C relationship. Consider the The “labels” dividing the different psycho- following examples. therapy models will no doubt cease to exist Experimental social psychology includes at some point. For now, however, we do not the well-known paradigm of “social facili- think it realistic this will happen in the near tation” (for a comprehensive literature future. As long as these oppositions purely overview, see Guerin, 1986). How does the spring from a difference in the terms used, presence of a socius influence a participant’s this does not pose any problems and instead behaviour? The presence of a socius some- is purely a matter of translating, with the times appears to facilitate or inhibit comple- precise choice of language guided by the tion of a task. The latter effect is then ascribed therapist’s aesthetic preference. But these to an increase in tension that especially ham- differences are likely of a more elemental pers the execution of more complex tasks. nature and interweaved with the fundamen- Using the existing experimental literature tal discussion about the core fundaments of and theories, every creative researcher can our basic discipline: psychology. 182 Eelen et al: The Therapist as Conditioned Stimulus

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How to cite this article: Eelen, P., Depreeuw, E., & Van Den Bergh, O. (2018). The Therapist as Conditioned Stimulus. Psychologica Belgica, 58 (1), 172–183, DOI: https://doi.org/10.5334/pb.454

Submitted: 13 April 2018 Accepted: 13 May 2018 Published: 26 July 2018

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