The importance of the therapeutic relationship in the efficacy of psychotherapy has become a widely recognized truth in the clinical field (Lambert & Simon, 2008). Carl Rogers’, an American humanistic psychologist and theorist, greatly influenced this knowledge base with the introduction of his “person-centered” approaches to clinical practice. Broadly speaking, Rogers’ hypothesis is that the person who presents in psychotherapy already has within them the resources, knowledge, and wisdom needed for healing, and that it is the work of the therapist to facilitate a therapeutic relational climate that enhances the client’s ability to draw upon their internal resources in the pursuit of growth and change (Rogers, 1942). This approach is of particular interest when applied to the treatment of eating disorders and attachment trauma. Although relatively little research has been pursued regarding the intersection of attachment wounding, trauma, and eating disorders, there is reason to believe that the three concepts are deeply interwoven and more often than not, clearly present in the lives of eating disordered clients (Costin, 2019). In attachment-based psychotherapy, we surmise that the relationship between the client and therapist is a potential site where attachment repair and repatterning can occur, creating new and positive relational experiences, and healing attachment wounds from the past. Carl Rogers’ three principles of person-centered therapy provide a framework for relationally focused clinicians who seek to understand how attachment-focused therapy operates in the context of eating disorder treatment. This paper will outline the three principles of Rogerian theory and describe their relevance to the project of building secure attachment in the therapeutic relationship with eating disordered clients.
The first principle of a person-centered approach to therapy is “genuineness”, which can also be described as authenticity, realness, and affective congruence on the part of the therapist. Essentially, genuineness is the process of clinicians showing up as their authentic selves from moment to moment in the therapeutic relationship. Rogers argued that it is through this foundation of authenticity that a meaningful and healing relational dynamic can begin to take place. The principle of genuineness asks us as clinicians to practice and model honesty for our clients, a practice that requires mindfulness of one’s own internal emotional experience in the present moment, as well as willingness to be vulnerable in sharing that experience in the therapy room. For most eating disordered clients who suffer from alexithymia (difficulty identifying and communicating emotions) and stunted interoceptive awareness (difficulty with mindful awareness of one’s body sensations and somatic experiences), modeling genuineness is critical for treatment, as clients slowly learn over time that it is safe to be an honest version of themselves in relationship.
Interestingly, the principle of genuineness allows the therapist to model another crucial skill in attachment-based work: acknowledging and tolerating internal and interpersonal dialectics. Learning how to hold two seemingly opposed truths simultaneously in the context of relationship is, in many ways, a developmental skill that is the product of a secure-enough attachment relationship in infancy and childhood (Ogden, 2004). For clients with attachment-related difficulty and eating disorders, this skill is often quite difficult and needs to be relearned. Dialectical Behavior Therapy aims to provide clients with skills that better equip them to tolerate the dialectics of life, and this approach is an undoubtedly helpful and effective intervention (Linehan, 2015). However, many relationally dynamic therapists tend to place greater attention on modeling acceptance of relational dialectics as they arise in the therapeutic dyad, rather than focusing on behavioral and skill-based approaches. In practice, this might mean the therapist verbally acknowledges their own dialectic experience in session. For example, if an eating disordered client disclosed to the therapist that their high-risk behaviors had increased during the past week, the therapist could model the principle of genuineness by expressing their own dialectical emotional reaction to this information in saying something like, “On the one hand, I’m relieved and glad that you feel safe to tell me this, and on the other hand I do feel concerned and even a little scared for your well-being”. Modeling genuineness is an experiential way in which eating-disordered and traumatized clients can begin to learn how to tolerate internal conflict that arises in authentic and genuine relationship.
Unconditional Positive Regard
The second principle of person-centered therapy is “unconditional positive regard”. In this principle, Rogers asks person-centered therapists to practice assuming the best about their clients, and to keep the client’s bigger picture in mind when working within the therapeutic relationship. Secure attachment is deeply related to a child’s felt sense that their caregiver can accept and tolerate their most acute pain, their deepest fears, and most hidden points of shame without falling into a rejecting or abandoning stance. Many eating disordered clients come to therapy and describe experiences of family dynamics that were characterized by fear of not measuring up, a sense of needing to earn love and support, and the experience of relational care as something that is unreliable. In turn, reliance on the eating disordered behavior becomes, among other things, a way of dissociating from and coping with the pain and insecurity of primary attachment relationships (Finlay, 2019). In the therapeutic relationship, unconditional positive regard is a reparative process that signals to the client that there is nothing that the client can do or say that will lead to rejection or abandonment from the therapist. Even in the face of conflict and relational rupture, the therapist aims to work from a place of curiosity, containment, and commitment to seeing beyond the immediacy of the client’s presenting problems, holding them in a place of hope, love, and respect. In this process, clients begin to learn that they are inherently valuable and that it is possible for them to exist as their fullest, truest selves in a relationship with an object who is able and willing to hold their bigger picture in mind, even in moments of emotional turmoil and relational rupture.
The final principle of client-centered therapy is what Rogers called “empathic understanding”. In empathic understanding, the therapist interacts in a way that allows the client to feel connected and understood on emotional, cognitive, and somatic levels. Winnicott’s writings about containment and the creation of a “holding environment” relate closely to this principle, namely the notion that an infant must first feel unified with the caregiver before they are able to begin tolerating the process of separation, ambivalence, and relational rupture (Winnicott, 1953). Similarly, in the therapeutic relationship we see the value of and perhaps necessity for the client to feel held, attuned to, and seen by the therapist before diving into the process of deeply seeing and understanding themselves.
An intervention from Sensorimotor Psychotherapy (SP), a somatic and attachment-based psychotherapeutic modality, illustrates a concrete way of creating empathic resonance and understanding. In SP, as in many modalities, a foundational task is the creation of a “container” between therapist and client. SP relies heavily on the use of “contact statements” in facilitating this process. Contact statements describe the therapist’s verbal and nonverbal efforts to make psychic contact with the client, letting the client know that the therapist is tracking with them, understanding them, and attuning to them (Ogden, et al., 2008). Contact statements are often made explicitly in the form of verbally repeating what the client has just said, verbally acknowledging an emotion that is coming up for the client or taking note of something happening in the client’s body. For example, as a client discusses a troubling relationship, the therapist might simply acknowledge what appears to be happening in the client’s body by saying something like, “As you talk about this, I see your hands shaking and your shoulders seem to be slouching forward.” These kinds of contact statements serve a dual purpose, as they draw the client’s attention to their own emotional and somatic experience (something that is difficult for most clients who have histories of trauma and eating disorders), as well as helping the client to sense that the therapist is attuning to their present experience, creating a feeling of being contained and understood.
Rogers’ person-centered theories are, at their core, rooted in the belief that the therapeutic relationship is the foundation of change and growth for the client. In this way, Rogers’ ideas are inherently relational and can serve us well in conceptualizing attachment-based psychotherapeutic healing. Clinical providers in the eating disorder field are coming to understand with more certainty the interconnectedness of attachment injury and the occurrence of eating disorders (Vanderlinden & Palmisano, 2019). For those who aim to practice from a relationally psychodynamic and attachment-based place in the treatment of eating disorders, Rogerian principles serve as a reminder that more important than what we do, say, or what specific modality we use, it is how we exist in relationship with a client that is essential in establishing a secure and healing therapeutic relationship. As Rogers beautifully asks in his essay on the creation of a helping relationship, “Can I be in some way which will be perceived by the other person as trustworthy, as dependable or consistent in some deep sense?” (Rogers, 1942) This, as I understand it, becomes our fundamental task as relationally-oriented clinicians treating eating disorders—to let our “way of being” create and sustain a reparative relational experience that, slowly over time, becomes characterized by honesty, trust, and stability.
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