The Humanistic Psychologist

© 2019 American Psychological Association 2020, Vol. 48, No. 2, 202–219

0887-3267/20/$12.00 http://dx.doi.org/10.1037/hum0000143

The Practice of Context-Centered Therapy:

A Conversation With Jay S. Efran
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Jonathan D. Raskin Jay S. Efran

State University of New York at Temple University
New Paltz

This article presents an interview with Jay S. Efran, the developer of context-centered
psychotherapy—an approach to psychotherapy greatly influenced by Humberto Maturana’s
structure determinism and George Kelly’s personal construct theory. Because Efran has
outlined the premises of context-centered therapy elsewhere, the interview focused on the
nuts and bolts of Efran’s independent practice, with the goal of illustrating how the way he
works reflects his theoretical commitments. Efran was asked how he contracts with clients,
structures first sessions, conducts the therapy that follows, and brings therapy to a conclusion.
In addition to discussing what he sees as the predictors of therapeutic success, he was also
asked about the size of his caseload, the duration of his sessions, the number of times he
typically meets with clients, whether he takes notes during sessions, his thoughts on the role
of medication in therapy, and how he handles insurance and billing. The interview concludes
with a case study and advice to psychotherapists-in-training.

Keywords: context-centered psychotherapy, private-practice guidelines, constructivism,

personal construct theory, structure determinism

Jay S. Efran— originally a student of George Kelly—practices a form of constructivist

psychotherapy that draws heavily on Humberto Maturana’s theory of structure determin-
ism. He has written about this “context-centered” approach in a variety of places (e.g.,
Efran, Lukens, & Lukens, 1990; Efran & Greene, 1996; Efran & Soler-Baillo, 2008; Efran
& Fauber, 2015). However, Jonathan Raskin—a constructivist psychotherapist who stud-
ied with Franz Epting, another of George Kelly’s students—wanted to know about the
nitty-gritty specifics of Efran’s method: how he selects clients, conducts a first session,
handles fees, and so on. To this end, Raskin invited Efran to respond to a series of
questions. Here is the conversation that resulted, preceded by a brief overview of
context-centered therapy for those unfamiliar with it.

This article was published Online First May 30, 2019.

Jonathan D. Raskin, Department of Psychology, State University of New York at New Paltz;
Jay S. Efran, Department of Psychology, Temple University.
We thank Gabrielle Phillips for her helpful comments on the manuscript.
Correspondence concerning this article should be addressed to Jonathan D. Raskin, Department
of Psychology, State University of New York at New Paltz, 1 Hawk Drive, New Paltz, NY
12561-2443. E-mail: raskinj@newpaltz.edu

202
 PRACTICE OF CONTEXT-CENTERED THERAPY 203

Context-Centered Therapy

Therapists have the option of addressing issues at the level of content, process, or
context (Efran et al., 1990; Efran & Fauber, 2015; Efran & Greene, 1996; Efran & Sitrin,
2002; Efran & Soler-Baillo, 2008). All of these approaches can be valuable, but—when
applicable—the contextual level is the most efficient. Consider, for instance, a client who
complains about always being late for work. A therapist might recommend that he
purchase an alarm clock. This would be a content-level intervention. On the other hand,
the clinician could focus on the nature of his relationship with his supervisor or boss—a
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process-level intervention that is characteristic of much contemporary therapy. However,

the therapist might also choose to explore the broader context in which the person’s
lateness occurs. What are his career goals? How does he construe his role in the firm?
What is important in his life? Contexts are the often unnoticed frameworks that allow and
shape the generation of meanings. Therefore, with shifts in context, everything changes,
including patterns of behavior. Contexts can be broad and inclusive, such as “marriage”
or “parenthood,” or narrow, such as a game of chess or a night at the ballpark. Context-
centered therapy seeks to put a spotlight on contexts that contain and maintain problematic
behavior. The advantage to working at the level of context is that contextual shifts can
happen in an instant, although the ramifications of such shifts may play out over a longer
period of time. In other words, it only takes a moment to go from being single to being
married, but the consequences of saying, “I do” last a lifetime.

The Conversation

Criteria for Taking on Clients

Raskin: Let’s begin at the beginning. What criteria, if any, do you use to decide
whether to take someone on as a new client?
Efran: I cannot remember the last time I refused to see a client. I will meet with
anyone who is willing to meet with me. I have worked with adults and
adolescents, individuals, couples, and an occasional family. In addition to
“ordinary” clients, I have seen motorcycle gang members, drug dealers,
showbiz celebrities, psychotic individuals and—sometimes the most chal-
lenging of all—therapists. The only demographic I tend to avoid is young
children—play therapy is just not my style.
I should add that I am always delighted to see clients who have failed with
other therapists. They present a kind of win-win situation. If the work is
successful—and it often is—it is viewed as some sort of miracle. However,
if it fails—as it sometimes does—the client usually gets the blame.
I also love working with clients who complain about “poor self-esteem,”
“low self-confidence,” “weak willpower,” “laziness,” “procrastination,”
“self-doubt,” “lack of courage,” and so on. These are all explanatory
fictions—not bona fide disorders. By unpacking their meanings, clients are
rather easily released from the linguistic spell they weave. For instance,
“procrastination” simply means successfully postponing tasks which (a)
you do not like, and (b) you do not have to do. (Obviously, no one escapes
doing tasks that they really have to do.) Once the term is demystified, it
 204 RASKIN AND EFRAN

becomes superfluous. To take another example, “self-confidence” is not

something you need when you set out to perform a task. As a wise person
noted, it is something you get when you do not need it anymore.

The First Session

Raskin: How do you approach a first session? Do you do any kind of formal intake
interview?
Efran: I dislike formal intake procedures. People arrive with pressing problems,
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and my goal is to address these as quickly as possible. There will be plenty

of time later to catch up on any missing background information, most of
which I find irrelevant anyway. I do have a set of HIPAA forms ready to
go—as the law requires— but I usually postpone having these signed until
the end of the meeting, when I can be reasonably sure that we will actually
be working together.
I almost always begin with my “universal opening gambit,” saying, “What
can I do for you?” I have found this query more productive than the typical
alternatives, such as “What is bothering you?” “What is the problem?”
“What brought you here?” and so on. My version puts the emphasis in
exactly the right place— determining the service the person is expecting to
receive. It is not enough to know what is troubling the individual. One also
has to know the person’s conception of the project ahead. Even a response
such as “I don’t know” is helpful because, as the social workers say, one
has to start where the client is. A vague answer tells me that the conver-
sation has to begin at a more fundamental level than it would with clients
who are savvier about the therapy process. From the outset, my focus is on
developing a clear contract. I have learned the hard way that a fuzzy
agreement is a formula for frustration and failure.
Midway during the first session, I generally stop to gather a few basic
facts, such as the person’s age, marital status, job, children—just
enough to “situate” the client in time and space. I generally jot down a
few details that I would otherwise forget, such as the names of the
person’s kids. However, as soon as possible, I put my notepad away.
Notepads get in the way of the robust person-to-person bond I am
working to create. Of course, before the client leaves, I make sure that
I have his or her contact information, the name of the referring
physician, and so on.
As I listen to the client’s story, I try to identify statements with which I can
wholeheartedly agree and a few that I intend to question. Points of
agreement strengthen the client-therapist bond. However, disagreements
contribute to the alliance by signaling that these sessions will generate
different, novel perspectives. Clients want to be understood, but they also
want to be challenged—they need fresh input. Otherwise, they might as
well stay home.
As part of this relationship-building process, I try to convey “understand-
ing beyond expectation.” In other words, I want the client to feel better
understood than he or she might have anticipated. The best way to do this
 PRACTICE OF CONTEXT-CENTERED THERAPY 205

is to make a few accurate predictions about what the client is experiencing

before those details have been spelled out. For instance, I might suggest to
a depressed individual that he or she is having sleepless nights or suffering
a loss of appetite. Voicing these “predictions” with a rising inflection
allows them to be interpreted as either statements or questions. Thus, if the
prediction turns out to be wrong—for instance, the person says, “No, I
have been sleeping just fine”—little has been lost. However, if my con-
jecture is right on target, the client will experience that moment of being
deeply understood that we all cherish.
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At some point, I propose a tentative therapeutic contract. For example, I

might say, “If we worked together for—let’s say—the next 6 weeks and,
as a result, your relationship with your coworkers and your boss improved
significantly, would you consider that a worthwhile achievement?” A
“yes” from the client indicates that we now have a workable agreement.
Other goals and details can be added later, but this is sufficient to enable
the process to proceed. In proposing a contract, I always try to include a
time line and identify goals that are—at least in principle—measurable. It
has been said that the mind loves generalities. Generalities provide wiggle
room. If I say, “be sure to visit us soon,” nothing happens. On the other
hand, if I say, “Please join us for dinner next Friday night,” we are very
likely to break bread together. The trick to successful therapy (or anything
else, for that matter) is to get specific.
I should add that when I talk about a therapy contract, I am not referring
to a written document. This is not something for the client to sign. It is a
verbal understanding that reflects the purpose of meeting and the antici-
pated outcome. Again, additional elements may be added and expectations
can be further refined, but it a mistake to proceed without a pact that
specifies the services being requested. Therapy may be a calling, but it is
also a business. Businesses require that a product be specified, even if it is
as abstract as “an improved sense of well-being.”

Beyond the First Session

Raskin: How do you decide whether to meet with a client again after the first
session?
Efran: By the end of the first session, I have a pretty good sense of whether or not
the client and I will make a good team. However, because I want to operate
with the strongest possible alliance, I sometimes impose an additional
condition before agreeing to a second appointment. I suggest that the client
go home and think about what transpired. From his or her perspective, did
the first session produce anything of value? Did it generate a different slant
on the problem? I want clients to answer such questions when they are by
themselves, free of the demand characteristics of having the therapist
present. If, after considering the matter, the potential client concludes that
we are the right team to address the problem, they should call to set up a
second visit. On the other hand, if nothing useful happened in that first
meeting, perhaps they would be better off working with someone else. In
that circumstance, I am happy to provide referrals.
 206 RASKIN AND EFRAN

I follow this procedure because I anticipate that there will be some rocky
moments ahead in our relationship, and I want a clear “team” commitment
from the client at the outset. I want to be able to say, “Listen, you signed
on for this trip.” I may also want to remind the individual that, as his or her
consultant, my job is to provide what is needed, not necessarily what is
popular or flattering. I am not running for political office!
I ask couples to decide separately about a second session. I want them to
each verify that they are in favor of continuing. Again, the work is much
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easier if both members of the couple endorse the project. It is much more
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difficult if one member of the couple is being dragged along or pressured

to participate. Over the years, I may have lost at most one or two cases by
following these procedures. On the other hand, giving clients a clear
opportunity to vote “yea” or “nay” about the upcoming journey has yielded
untold benefits.
When therapy involves more than one person, I also insist on the right to
see each of them separately. I agree to maintain confidences about any
facts that come to light in these private sessions until or unless they have
been made public. There are some tasks that are best accomplished with
everyone in the room and other tasks that can only be addressed in separate
meetings. For instance, some partners are secretly involved in an affair that
they may or may not be willing to disclose and may or may not be willing
to give up. My position is simple: I would rather be privy to that sort of
information than operate in the dark.

Session Length, Scheduling, and Caseload

Raskin: How long does the first session usually last? Do you stick to the traditional
50-min hour in initial and/or subsequent sessions? Why or why not? How
often do you see clients? Weekly? Biweekly? More or less often?

Efran: I have a unique approach to scheduling. I charge by the session, not the
clock. I always have to explain this to new clients. I like to say that I am
following the “surgical model.” Surgeons never announce that “time is up”
in the middle of an operation. They may estimate how long a given
procedure is likely to take, but when there are surprises or miscalculations,
the completion of the operation takes precedence over other consider-
ations.
The phrase “the show must go on” was coined for the convenience of
producers, not actors. Similarly, the notion that therapy sessions should
begin and end at a set time was an invention of clinicians, not clients. The
problem is that although some issues can be dealt with in just a few
minutes, others require more than an hour to resolve. My focus is on the
task rather than the tradition. Therefore, I have had sessions that last as few
as 10 min and a few that go on for close to 3 hr. Over the years, the
majority of my sessions run about an hour— give or take 10 or 15 min.
However, my goal is to end at a natural juncture rather than because 45, 50,
or 60 min have elapsed.
 PRACTICE OF CONTEXT-CENTERED THERAPY 207

I leave some leeway in my schedule to accommodate this self-imposed

unpredictability. Of course, there are occasions when my schedule or the
client’s schedule prohibits arriving at a point of satisfactory closure. In
those instances, we arrange to pick up where we left off as soon as
possible. This is not a tragedy, but it is not my preference and it happens
only rarely.
I have been given all sorts of grief about my elastic scheduling,
particularly from psychoanalytic brethren. They warn that the absence
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of strict session boundaries is detrimental to the client, and/or that

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clients will manipulate the situation by bringing up crucial issues

toward the end of a meeting. As far as I can tell, neither of those
dangers has materialized. Actually, in my arrangement, it is harder for
clients to withhold important material until late in the session because
the endpoint is not predetermined. Mainly, I have found that clients—
particularly those who have had experience with other clinicians—are
deeply grateful not to be interrupted in the middle of a crucial conver-
sation by the therapist pointing to the hands of the clock.
I also avoid scheduling regular, weekly sessions at predetermined
times. From my perspective, the “same time, next week” gambit sets up
all the wrong expectations. It implies that nothing much needs to
happen until we meet again, and that these meetings can be expected to
continue in perpetuity. I recently spoke to a clinician who has been
meeting regularly with a client for the past 10 years with no end in
sight. By contrast, I want to convey that I expect a lot to happen
between meetings—in fact, that is where most of the “action” ought to
take place. Also, as with any work project, the dates and times of
meetings should reflect the needs of the mission rather than an artificial
calendar setting. My custom is to schedule the next session at the
conclusion of the current one, based on an assessment of the project’s
status. Rather than anticipating years of meetings, I anticipate obtaining
substantial results in a few weeks or a couple of months.
It was Carl Rogers (1959) who pioneered the notion that clients be seen
once weekly rather than the six times per week that had been the
analytic tradition. This was considered heretical at the time. I am
suggesting that we go one step further, seeing clients as the need
dictates, rather than on the basis of an arbitrary time schedule.

Raskin: What percentage of your caseload are individual clients, couples, and
families?

Efran: These days, 70% individuals, 20% couples, and 10% families.

Raskin: Given that you do not cap sessions at an hour, my guess is you do not see
a full-time caseload of 30 – 40 clients per week. How many clients do you
see weekly? How would you respond to full-time therapists who contend
that they cannot afford to charge by the session rather than the hour and
that—to the contrary—they must limit sessions to the traditional 50-min
hour in order to make a living.
 208 RASKIN AND EFRAN

Efran: You are right. I do not maintain a full-time caseload. My academic

contract allows one day of independent practice per week. Of course, I am
free to see additional clients at night or on the weekend. The number of
clients I see each week varies because of my predilection for avoiding
routine weekly sessions. I would say that the average is eight— give or
take three. I do think my circumstances make scheduling by task rather
than time easier for me than it would be for those in full-time independent
practice. However, some therapists whom I have influenced have imple-
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mented modified versions of my plan without experiencing severe income

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shortages. Partly, it is a matter of values—I chose to provide clients with

what I think they need rather than what enhances my bank-account
balance.
I recall that years ago George Kelly declined an offer to be chair of the
City College of New York psychology department. The salary offer was
more than generous. However, he concluded that their faculty members
were required to teach too many semester-hours—a condition that he felt
stymied their creativity, both as teachers and researchers. Similarly, to jam
too many clients into the day potentially limits one’s ability to think
flexibly about what each case requires. Thus, more is at stake than just
session length.

Location of Therapy
Raskin: Where do you see clients (home, office, somewhere else)? Is there a reason
you like to use this setting?
Efran: When I became director of clinical training at Temple University, I
negotiated for the privilege of seeing private clients at my university office.
Also, I have always seen clients at my home office. Here again, my analyst
friends have worried that because I do not have separate entrances, clients
might cross paths with each other or— heaven forbid—run into family
members. I think such matters only become issues if you treat them as
such. When a client runs into a member of my family, I introduce them!
No big deal. To me, therapy is not a secret or sacred endeavor—it is an
ordinary part of my life. I have the advantage of never having concerned
myself about “threats to the transference.” Perhaps because I interned in a
small town (Durham, NC), I am accustomed to encountering clients at the
supermarket, the gym, the movie theater, or a social event. None of this
bothers me. Those who feel the need for a more protected environment will
have to go elsewhere.
There are times when I have met with clients in other settings for
specialized purposes. I spent the better part of a day with a highly phobic
individual at a nearby amusement park—an ideal place to “play” with fear
in a safe, controlled environment. I met a distraught client at 3 a.m. at an
all-night diner. He had been locked out of his house by his irate spouse. I
picked up a heavily drugged, suicidal individual at the phone booth from
which he called and convinced him to let me drive him to the hospital. I
visited a housebound agoraphobic client at his parent’s home. I saw a
homeless client on the street, in front of the car in which he was living.
 PRACTICE OF CONTEXT-CENTERED THERAPY 209

These are rare circumstances, but I have no compunctions about making

special arrangements when the occasion requires. There is nothing sacro-
sanct about meeting in an office.

Insurance and Fees

Raskin: Do you take insurance? If so, does how you proceed differ with clients
who use insurance versus those who do not?
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Efran: I am willing to provide an invoice (including a diagnosis) for individuals

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seeking insurance reimbursement. However, I have not joined any insur-

ance panels, and I leave negotiations with the insurance company up to the
individual. I charge the same fee whether or not the person receives
reimbursement.
I accept cash or checks at the end of each session. I do not do any billing,
but I am perfectly willing to wait until the following session if a person has
forgotten their checkbook or is a bit short on cash.

Challenging “Sacred Therapeutic Cows”

Raskin: Are there notable ways in which what you do in therapy seems to differ
significantly from what is “typical?” That is, are there any “sacred thera-
peutic cows” that you think shouldn’t be so sacred and that you regularly
disregard?
Efran: I have already mentioned some distinct differences in how I work. Many
of these derive from my view that therapy consists of a project or a series
of projects rather than an open-ended pity party or a deep-dive into the
person’s childhood memories. I agree with George Kelly that it is prema-
ture to establish any firm lists of professional dos and don’ts since we still
know so little about mental health or human behavior.
I am reminded of a Grand Rounds held years ago at the University of
Rochester Medical School. The assembled psychiatrists were discussing
the dangers of symptom substitution—the notion that if you achieved
symptom relief without exploring the underlying psychic cause of the
problem, the patient would develop a series of new, “substitute” symptoms
that might be worse than those that were eliminated. At a pivotal point in
this discussion, one of the newer, maverick members of the faculty
stood up and asked if anyone in the room had actually seen a case of
symptom substitution. Not a single hand went up. Thus, everyone
believed in and was concerned about a phenomenon that nobody had
witnessed, and which most of us now believe never existed. My guess
is that any number of our cherished clinical beliefs and practices are
equally apocryphal.
Kelly was an experimentalist at heart, and so am I. In that vein, I pay
attention to anyone who claims to have discovered or invented a more
effective or efficient therapy method. Thus, over the years, I studied
reevaluation counseling, systematic desensitization, and implosion ther-
apy. I participated in encounter groups and the est seminars. I attended a
 210 RASKIN AND EFRAN

weekend of EMDR training, did workshops on reality therapy, transac-

tional analysis, DBT, solution-focused methods, emotionally focused ther-
apy, internal family systems, Bowenian family therapy, psychodrama,
motivational interviewing, and much more. Although I have absorbed
useful bits of information from all of these modalities, I am not a devotee
of any of them. Frankly, I am more impressed by what they have in
common than by ways in which they differ.

Notes and Recordkeeping

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Raskin: Do you take notes during sessions? Why or why not? What kind of client
records do you keep (intake information, process notes, etc.) and why?
Efran: As I mentioned, I avoid taking notes during a session. At most, I jot down
those few logistic items that I will need for record-keeping purposes. At
the end of each session, I write a progress note— usually no more than
three sentences. It serves as a reminder about topics discussed and steps
planned. Sometimes, I make a note about a metaphor or example that
seems to have had strong impact. I also note any personal stories I shared
with the client because I hate repeating myself. Otherwise, my clinical
records are bare-bones. They include the date of each session, the starting
and ending time, and the fee paid. There is also room to annotate special
circumstances, such as the presence of a visitor or the gist of a conversa-
tion with the person’s psychiatrist.
Raskin: You mention that you keep track of which personal stories you have shared
with clients. Are there some that you tell repeatedly because they have
proven so helpful? Are you willing to mention one of those?
Efran: Some anecdotes are particularly useful because they address such univer-
sal concerns. For instance, I often describe the fears I experienced while
learning to ski. This includes the very embarrassing moment when I found
myself sprawled on the slope, unable to figure out how to get up, and being
taunted by an 8-year-old girl who whirled around me, gleefully muttering,
“How come you can’t ski?” Dealing with fear and embarrassment is
something everyone understands.

Medication
Raskin: What role does medication play when working with clients? Do you
encourage clients to pursue medication? Do you work closely with psy-
chiatrists or other professionals to refer clients for medication? Why or
why not? If so, under what circumstances?
Efran: I am not opposed to the use of medications nor am I always impressed with
their effectiveness. There are exceptions. For example, I have seen dra-
matic improvement attributable to antipsychotic drugs. In one case, I had
the opportunity to observe a person’s behavior as his medication was
withdrawn and later reinstated. Before being medicated, this individual
experienced a variety of paranoid delusions, including the idea that neigh-
bors were sneaking into his apartment, stealing his possessions and rear-
 PRACTICE OF CONTEXT-CENTERED THERAPY 211

ranging household objects “just to drive him crazy.” With medication,

those delusions totally disappeared. However, when the medication was
withdrawn, the delusional thoughts gradually returned, first in the form of
“annoying ideas” and then as full-fledged delusions.
I have also had clients report receiving substantial relief using antianxiety
meds, particularly when their jitteriness was a reaction to an immediate
traumatic event, such as a relationship breakup, a job loss, or the death of
a close friend or relative. I have not seen as salubrious effects with the
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various antidepressants. I construe pharmaceutical effects as somewhat

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akin to “volume controls.” They do not change the person’s basic circum-
stances, but they can “turn down” the level of distress. This, in turn, can
increase the person’s ability to think clearly and develop more effective
coping mechanisms.
Only rarely have I needed to encourage clients to seek medication. More
often than not they are already on some kind of psychotropic drug. I have
sometimes recommended that the person arrange a drug holiday. Some
people have been on so many meds for so many years that they are no
longer clear about what is doing what to whom. Obviously, I insure that
any such “holiday” is undertaken responsibly, with the consent and coop-
eration of the prescribing physician. In a similar vein, I have sometimes
advised a thorough medication review because it had come to light that no
single prescriber had full awareness of the person’s medication regimen.

Inviting Others Into Sessions

Raskin: When you work with individuals, do you ever invite in family members or
other important people from their lives?

Efran: Absolutely. However, when someone from the client’s life “visits,” I
always meet with that individual alone before launching into a joint
session. I justify this by explaining that although the client and I know each
other (and are informed about each other’s positions), I need an opportu-
nity to get acquainted with the new individual and learn something about
his or her viewpoint. Again, as with couples, I explain that I will maintain
confidentiality about anything I learn in a private meeting. It is also crucial
that any visitor understand that although I have been hired by the client, the
visitor will be given a fair hearing—they are not there to be “made wrong”
or ganged up against. Over the years, I have had excellent success gaining
the trust and cooperation of family members who initially thought that I
might be prejudiced against them.
I suppose I should add that the participants in a person’s life are always in
the therapy room, whether or not they happen to be there “in person.” As
systems therapist Richard Rabkin (1970) notes, a therapy conversation is
an interface between the client’s community and the therapist’s (profes-
sional) community. Thus, although we often call it “individual” therapy, it
is always a communal event.
 212 RASKIN AND EFRAN

Duration of Therapy
Raskin: How many sessions do you typically have with clients? Over how long a
period of time?
Efran: As I implied earlier, I want to have as few sessions as possible. Five to 10
is typical. I periodically check on progress by posing the following
question: “If we consider that your problem was at a 100% level when you
came in, what percentage would you say it is at now? If it has been
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completely solved, it would be at 0%. If it is even worse now than when

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we started, it might be at, let’s say, 120% or 150%. If it is partially

handled, it might be at 34% or 27%.”
In giving these percentage examples, I cite unusual numbers, such as 52,
38, 77, under the (possibly mistaken) belief that this encourages the person
come up with a considered metric, even though the process is entirely
subjective. And, to a surprising degree, they do come up with very specific
estimates—sometimes adjusting them up or down as they give them voice.
For example, the person might say, “I think we are at 41 . . . no, 37%.” My
follow up question is, “Okay. What is in the way of that dropping to 0?”
or “What is keeping the number at that level?” Perhaps any other scale of
progress would do as well, but this is the format to which I have grown
accustomed and I find it very helpful in determining where we stand and
what needs to come next.

“Completion” of Therapy Rather Than “Termination”

Raskin: How do you know when you and a client have finished your work
together? Is the decision to bring therapy to a close made by you, the
client, or both of you together? Why do you do it this way?
Efran: This is probably the place to say that I never terminate a client. In fact,
I find the whole notion of “termination” abhorrent. This is one of the
few instances in which I happily adopt an element of the medical
model. My internist does not “terminate” me. I have a fever. He does
a lab test. He prescribes an antibiotic. The fever goes away. That’s it for
the moment. However, I am free to call and make another appointment
whenever the need arises. The fever is gone, but our relationship
continues. Similarly, a project with a client may be nearly complete.
Thus, it may now be appropriate to wait for a month or so before
checking in with one another. Later, perhaps just a phone contact will do.
So, the frequency and form of contact changes, but no formal termination is
required. I have clients who recontact me, sometimes years later, in connection
with a new relationship, a job loss, a family crisis, and so on.
Philosophically speaking, once I meet a person—for whatever reason,
personal or professional—I assume that he or she will remain part of the
cast of characters of my life forever. Perhaps they will not always have a
starring role, but they are a permanent member of the “company.” That is
why I consider termination an artificial and “ugly” notion. It is no wonder
that clinicians puzzle over all kinds of questions in connection with how
and when to terminate clients—it is an unnatural act.
 PRACTICE OF CONTEXT-CENTERED THERAPY 213

Raskin: This is a helpful alternative to traditional ways of thinking about “termi-

nation.” Can you clarify whether you or the client decide when your work
is completed? I ask because in the medical model that you emulate as an
alternative to “termination,” it is the doctor who usually determines when
the treatment is finished. So, if, after a contracted number of sessions, the
client rates the problem as mostly handled (say, 15% or lower on the
100-point percentage scale you use), do you say, “Well, I think our work
here is done”? If you do, how do your clients typically respond to this?
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What do you do with clients who do not wish to stop therapy, even when
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they rate the problem you contracted with them to address as mostly or
completely resolved? I ask because a lot of therapists seem hesitant to be
the ones who decide when the therapy ends.

Efran: I have to disagree with your premise that the doctor decides when treat-
ment ends. In most cases, it is the patient who determines whether an
additional phone contact, office visit, or prescription change is required.
However, in terms of the therapy I do, the sense of completion is usually
mutual. Sometimes, I do say something such as “I think perhaps our work
is done,” but it is rare that the client does not concur. It is almost
immaterial who first voices the subject. Now, I have had a few cases in
which I continued to meet with a client even though I considered the
project over. I recall telling one of these clients that I had little more to
add—we were already repeating what we had said to each other in
previous sessions. The client agreed. However, given that for him money
was no object, he asked if I objected to continuing to meet for a while, so
that he could enjoy rehashing what we had discussed. I had no strong
objection, and we met about twice a month for another several months.

Predictors of Success
Raskin: Are there any predictors of therapeutic success that you look for in clients
or their circumstances?

Efran: There are certainly circumstances that make the work more difficult. The
first is when, for some reason, I have too much riding on the outcome. For
me, this happens when the client is a celebrity or the relative or friend of
a person I know well. Paradoxically, it is at times like these, when you
want to do your best work, that doing good work becomes difficult. To
think creatively, you have to “not care.” Alan Watts (1961) puts it this
way: “It is a great disadvantage to any therapist to have an ax to grind,
because this gives him a personal interest in winning. . . . But we saw, in
reference to the Zen master, that he can play the game effectively just
because winning or losing makes no difference to him” (p. 158).
A related obstacle is having too much overlap between my own beliefs and
those of the client. Novelty—what Maturana calls “orthogonal interaction”
(Efran & Clarfield, 1992, p. 192)—is a crucial component of therapeutic
success. But when client and therapist are members of the same “clubs,”
thinking outside the box becomes more difficult. The clinician too readily buys
into the very same strictures that limit the client’s world.
 214 RASKIN AND EFRAN

Finally, there is the problem of individuals who arrive with ulterior motives.
For instance, they are following their attorney’s advice, seeking therapy to
increase their chances of winning a custody battle. Some people come to
therapy to convince their parents not to cut off financial support. In one
recent case, the person wanted to see what therapy sessions were like
merely to determine if he would like a career as a therapist. In all of
these cases, and many more, we are faced with a sham. Until or unless
this can be converted into something genuine, it is unlikely that
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anything useful will transpire.

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Core Principles
Raskin: Are there any core principles that serve as a framework for guiding your
clinical work? What are they and why are they important?

Efran: Answering that question runs the risk of turning this into a lengthy,
theoretical discourse about the principles of structure determinism. How-
ever, let me take a stab at a couple of basics. I approach the work knowing
that my core responsibility is to perturb the client’s worldview—in small
and large ways. My goal is to precipitate a shift in the client’s perspective
and system of beliefs so that issues they viewed as immutable are expe-
rienced as malleable. I need for them to truly get George Kelly’s (1969)
notion that “Whatever exists can be reconstrued” (p. 227). In addition, I
want to encourage them to exchange strategies of avoidance (weak) for
strategies of mastery (potent). To accomplish this, I harness the power of
metaphor. In my view, metaphor is one of the unsung heroes of the human
change process. It is through metaphor that we can get an advance peek at
where we might be headed and find the inspiration to make the leap from
where we are now to where we want to be. In session, metaphor is
conveyed through anecdotes, humor, role plays, logical challenges, and
demonstrations. There is no standard set of techniques, because each client
is different and only the reaction of the client matters. This is truly an
experimental enterprise. However, I am buoyed by the clinical mantra of
Adlerian therapist Harold Mosak. He would tell students that although he
is not always certain about what to do next, he is certain that there is
always something to be done (Mosak & Maniacci, 1998).
In addition to metaphor, I trust in the process of telling “the truth.” As
Gloria Steinem presumably said, “The truth will set you free, but first it
will piss you off.” By the truth I am referring to the person’s experiential
truth. As constructivists, we know that there is no point in talking about
any kind of absolute truth, because such a thing is beyond our ken.
However, it is in the domain of the person’s experiential truth that the
therapeutic game has to be played. I recall a client trying to decide whether
to tell his wife about his extramarital affair. At some level, he already
knew (a) that she was aware of the affair, and (b) that he was going to have
to confess. However, he was not quite ready to accept that painful truth.
Thus, we argued back and forth until he ran out of dialogical “ammuni-
tion.” At that point, he looked at me and weakly embraced the argument
 PRACTICE OF CONTEXT-CENTERED THERAPY 215

of last resort: “Well, who listens to you, anyway?!” He told her the next
day.

Common Therapeutic Fallacies

Raskin: What are the most significant fallacies that you think bedevil current
psychotherapy practice?
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Efran: Let me go out on a limb and name five common beliefs that I consider false
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and which I think hinder the therapeutic process. First is the notion that
therapy is a treatment. In fact, we have no treatments. All we can offer is
conversation—which can be quite powerful. We provide a setting in which
the truth can be told and new options can be explored.
Second is the idea that therapy is about feelings. Feelings are best con-
sidered effects rather than causes. In structure determinism, feelings are
defined as perceptions of shifts in hormonal and musculoskeletal settings.
The notion that mental illness is caused by “pent up feelings” that need to
be expressed is a hold-over from primitive “steam-kettle” thinking. The
culture is rife with colorful metaphors such as “letting off steam,” “boiling
with rage,” and being “drained after a good cry.” However, despite their
experiential appeal, such notions have no biological validity (Efran & Greene,
2012). What we store are memories and images—not feelings. Yes, when
events are recalled and recreated, bodily calibrations are affected. However, it
is the event itself that is the proper focus of therapy.
The third false belief is that therapy should be about correcting mal-
adaptive thinking patterns. The research shows that most clients think
about as well as any of us. None of us thinks well when our physical
or psychological survival is threatened. When such threats are reduced
or removed, “maladaptive” thinking clears up automatically.
Fourth is the belief that therapy hinges on the power of explanation.
Human beings can explain anything. As someone said, “We are never
caught with our explanations down.” However, explanations are second-
ary—not primary. Often, they are after the fact. Moreover, explaining is
not the same as creating, and it is on the generation of alternatives that
therapy should focus.
Fifth is the widespread misconception that therapy is about the past. It is
not; it is about “now.” The purpose of the past is to justify the present,
which it does exceedingly well. However, it has no sway over the future.
I recall a client who complained that he did not know how to break his
longstanding habits from the past. I suggested that although he brushed
his teeth every day—surely a very longstanding habit—it would be
easy enough to skip doing so the following morning. No special “habit
breaking” skill was required. Even those responses that involve muscle
memory—such as operating a clutch—adapt quickly to changing
circumstances.
 216 RASKIN AND EFRAN

Case Example
Raskin: Can you share a case example that highlights the main ideas you have
outlined and provides an overview of your therapeutic approach from start
to finish?
Efran: Matthew1 was a 58-year-old successful businessman who complained of a
lifelong pattern of depression and anxiety. He attempted suicide at the age
of 12. Although he had never met his biological father, he recalls telling
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his stepfather that he wanted to grow up to be just like him. In response,

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his stepfather smacked him so hard that he ended up on the floor.

Matthew described himself as something of a fraud, who had “bumbled
into” his successful business career. He seemed to expect that I would
argue against his low self-evaluation. However, I knew better than to go
down that path—it was obviously the approach that everyone else, includ-
ing his ex-wife, had taken. My approach is to find the path not taken. Thus,
I pointed out that he was indeed a fake—just like the rest of us. To prove
my point, I shared a quote from an article by Werner Erhard—the creator
of the est training. Here is part of that excerpt:

Every one of us has an act—a front—a façade—a mask we wear in the world
that tells the world who we are pretending to be. We think we need this to get
along in life and be successful. Underneath that mask is the person we are
afraid we are—the person who thinks those small, nasty, brutish thoughts we
try to hide, because we think we are the only one who thinks them, until
we are willing to accept that we do actually think them, and only then notice
everyone else does too.

All of us who are given credit for being intelligent have feelings, thoughts,
and so forth of stupidity and ignorance. All of us who are given credit for
being wonderful have doubts. In my observation (which includes a fairly
intimate interaction with over 90,000 people) we all have doubts about the
authenticity of the way we present ourselves in the world. (Erhard & Gioscia,
1977, pp. 110 –111)
Matthew found the quote revelatory, and as we explored this and a number of
related topics, such as guilt and marital infidelity, he reported feeling that an
enormous burden had been lifted from his shoulders. In our third meeting,
Matthew admitted that he often contemplated suicide. Once again, I drew
upon an item from my rather extensive collection of quotes, this time citing
Nietzsche’s (1886/2015) statement that “the thought of suicide is a great
consolation; with the help of it one has got through many a bad night” (p. 66).
Matthew thought that if he was going to kill himself, he should do it before
his two young grandchildren—whom he adored— got any older. He pre-
sumed that if he did it while they were still young, it would not negatively
impact their lives. I quickly disabused him of that notion. From my
perspective, he had the perfect right to do away with himself, but if he did,
he should do so understanding that it will certainly have an effect on his

1
The client has been deidentified by changing names and other details that do not affect the
interpretation of the case.
 PRACTICE OF CONTEXT-CENTERED THERAPY 217

grandchildren. This statement illustrates my commitment to go with the

truth and my willingness to firmly disagree with clients when necessary.
Over the next couple of sessions, we talked in detail about suicide.
Matthew found it a great relief to have found a place where he could speak
freely about the subject, without fear of being judged, upsetting others, or
having to sign a nonsuicide pact. We laughed about his claustrophobic
fears of being buried underground and pondered whether cremation was a
better option.
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Following this meeting, Matthew said, “For the first time in therapy—with
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anyone—I feel I am actually changing.” And, indeed, he looked and

sounded better. We had a few more sessions. One of these focused on his
anger toward some of the people in his life. I shared my notion that anger
is “blocked action”—a muted form of the desire to annihilate others.
Moreover, even though anger is usually directed at others, it also repre-
sents dissatisfaction with some aspect of ourselves. What we need are
ways to unblock the action without doing social harm— our open discus-
sions of his rage were a helpful step in that direction.
In one of our concluding sessions, we discussed Albert Schweitzer’s notion
that satisfaction involves being of service to others. Matthew, like most of us,
was spending far too much time focusing on himself rather than figuring out
how he could be of use to others. He agreed to take stock of how he had been
treating his employees and coworkers, some of whom had provided him with
many years of loyalty, helping to make his business a success. Matthew and
I met for a total of 11 sessions. We remain in touch and recently reconvened
to discuss a new romantic relationship—an event he would not have foreseen
when we first met.

Conclusion: Advice for Psychotherapists-in-Training

Raskin: As a nice way to bring things to a close, do you have any advice for
psychotherapists-in-training— or, for that matter, psychotherapists in
general?

Efran: First, be yourself. I fully agree with Marsha Linehan, the originator of
dialectical behavior therapy, who said that novice clinicians try too hard to
act like therapists: “If they would act like themselves, they would [be
better off]” (Feldman, 2000, p. 13). If, as a new therapist, your client asks
if you have lots of experience, you might say something truthful such as,
“No, but I have lots of enthusiasm and a terrific supervisor. Working as a
team, I am sure we can get a lot done.”
I also like the advice given to new clinicians by psychoanalyst Sidney
Rubin. He reminded them that it is the therapist’s job is to be confused and
the client’s job to clarify. It is not a sin to be perplexed or to ask additional
questions until the fog lifts. I also recommend keeping in mind the
context-centered therapist’s mantra: “No orthogonality, no progress.”
Therefore, one constantly listens for the unexamined assumption, the
constraining context, the road not taken.
Finally, even experienced therapists—who ought to know better—too often
become ensnared in the client’s description of the problem. Clients are clients
 218 RASKIN AND EFRAN

because they ask themselves the wrong questions. It is the therapist’s job to
help them pose better questions. Being in a rush to respond to the client’s
initial formulations can land the therapist in the same linguistic soup in which
the client is drowning. It was Albert Einstein who reputedly said that we can
never solve a problem using the language with which it was created.

References

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McNamee & K. J. Gergen (Eds.), Therapy as social construction (pp. 200 –217). London,
England: Sage.
Efran, J., & Fauber, R. (2015). Spitting in the client’s soup. Psychotherapy Networker, 39, 30 –37,
46 – 48.
Efran, J. S., & Greene, M. A. (1996). Psychotherapeutic theory and practice: Contributions from
Maturana’s structure determinism. In H. Rosen & K. T. Kuehlwein (Eds.), Constructing
realities: Meaning-making perspectives for psychotherapists (pp. 71–113). San Francisco, CA:
Jossey-Bass.
Efran, J., & Greene, M. (2012). Why we cry: A clinician’s guide. Psychotherapy Networker, 36,
43–48, 60.
Efran, J. S., Lukens, M. D., & Lukens, R. J. (1990). Language, structure, and change: Frameworks
of meaning in psychotherapy. New York, NY: Norton.
Efran, J. S., & Sitrin, L. C. (2002). Context-centered therapy. In E. A. Gosch & R. A. DiTomasso
(Eds.), Comparative treatments for anxiety disorders (pp. 137–159). New York, NY: Springer.
Efran, J. S., & Soler-Baillo, J. (2008). The mind and self in context-centered therapy. In J. D. Raskin
& S. K. Bridges (Eds.), Studies in meaning 3: Constructivist therapy in the real world (pp.
85–105). New York, NY: Pace University Press.
Erhard, W., & Gioscia, V. (1977). The est standard training. Biosciences Communications, 3,
104 –122.
Feldman, D. B. (2000). Blood, sweat, and careers II: Marsha Linehan and C. R. Snyder offer stories
and advice for graduate students. Clinical Psychologist, 53, 12–17.
Kelly, G. A. (1969). Clinical psychology and personality: The selected papers of George Kelly (B.
Maher, Ed.). New York, NY: Wiley.
Mosak, H. H., & Maniacci, M. P. (1998). Tactics in counseling and psychotherapy. Belmont, CA:
Brooks/Cole Publishing Company.
Nietzsche, F. (2015). Beyond good and evil (H. Zimmern, Trans.). Overland Park, KS: Digireads
.com Publishing. (Original work published 1886)
Rabkin, R. (1970). Inner and outer space: Introduction to a theory of social psychiatry. New York,
NY: W. W. Norton.
Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships, as developed
in the client-centered framework. In S. Koch (Ed.), Psychology: A study of a science (pp.
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Watts, A. (1961). Psychotherapy east and west. New York, NY: Vintage Books.

Author Note

Jonathan D. Raskin is a professor in the Department of Psychology at the State

University of New York at New Paltz, where he serves as chair and teaches classes in
psychology and counselor education. Dr. Raskin’s research focuses on constructive
meaning-based approaches in psychology and counseling, especially their applications to
understanding abnormality and psychotherapy. He recently authored a textbook, Abnor-
mal Psychology: Contrasting Perspectives, published by Red Globe Press, an imprint of
 PRACTICE OF CONTEXT-CENTERED THERAPY 219

Macmillan International Higher Education. He is also managing editor of the Journal of

Constructivist Psychology. Jonathan D. Raskin is licensed as a psychologist in New York,
where he maintains a private practice.
Jay S. Efran received the Pennsylvania Psychological Association’s 2009 award for
“Distinguished Contributions to the Science and Profession of Psychology” and the
Constructivist Psychology Network’s 2006 Lifetime Achievement Award. He is also the
recipient of two teaching awards— one from the University of Rochester and one from
Temple University. At Temple, he served as both Director of Clinical Training and
Director of the Psychological Services Center. A therapist for more than 50 years, he has
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

co-authored two books and published more than 100 articles and chapters on topics such
as emotion, social phobia, temperament, addiction, constructivism, contextualism, and
psychotherapy.
Received March 13, 2019
Accepted April 8, 2019 䡲