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Facilitating client change: Principles based upon the experience of eminent


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DOI: 10.1080/10503300903476708 · Source: PubMed

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Facilitating client change: Principles based upon the experience of eminent


psychotherapists
Heidi M. Levitt a;Daniel C. Williams a
a
Department of Psychology, University of Memphis, Memphis, Tennessee, USA

Online publication date: 23 April 2010

To cite this Article Levitt, Heidi M. andWilliams, Daniel C.(2010) 'Facilitating client change: Principles based upon the
experience of eminent psychotherapists', Psychotherapy Research, 20: 3, 337 — 352
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Psychotherapy Research, May 2010; 20(3): 337352

Facilitating client change: Principles based upon the experience


of eminent psychotherapists

HEIDI M. LEVITT & DANIEL C. WILLIAMS

Department of Psychology, University of Memphis, Memphis, Tennessee, USA


(Received 3 June 2008; revised 3 November 2009; accepted 9 November 2009)

Abstract
Eminent therapists across psychotherapy meta-orientations were asked to describe the processes by which they facilitate
change in psychotherapy. A grounded theory analysis of these interviews was conducted. Safety within the psychother-
apeutic relationship was identified as a central element in creating client change to the extent that in-session risk taking was
important in that orientation. As well, common processes across orientation in structuring new awareness emerged as a core
finding. Patterns were identified in how therapists balanced negotiating the clienttherapist relationship while fostering new
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awareness. Principles based on therapists’ common intentions are put forward to guide future research and psychotherapy
integration efforts.

Keywords: psychotherapy integration; alliance; grounded theory; therapists; psychotherapeutic relationship

Over the last two decades, a great deal of meta- (2001) review of the literature on alliance suggested
analytic research has been conducted on the psy- that therapists who were uncertain, critical, distant,
chotherapy relationship, much of which has focused tense, or distracted had poorer alliances. Those who
on the role of the therapeutic alliance and its overstructured the therapy, disclosed inappropri-
contribution to outcome (e.g., Abouguendia, Joyce, ately, or relied too heavily on transference interpre-
Piper, & Ogrodniczuk, 2004; Ackerman & Hilsenroth, tations or silence also had compromised alliances. A
2001; Horvath & Symonds, 1991; Martin, Garske, challenge with this literature is that therapists may
& Davis, 2000). Although different definitions have have multiple intentions at any one moment (e.g.,
been put forth, there is some consensus that it needs to attend to interventions, alliances, boundary
describes the collaborative aspect of the therapeutic setting) and may have clients with differing needs,
relationship, in which client and therapist together and so decontextualized proscriptions against any
negotiate the focus and the depth of their relation- one behavior (e.g., structure) can be difficult to
ship, and scales assessing the working alliance have follow. Client and therapist attachment styles have
demonstrated strong intercorrelations (Horvath & been shown in some research to influence the
Symonds, 1991). This body of research has shown a alliance (e.g., Black, Hardy, Turpin, & Parry, 2005;
moderate but consistent relationship between psy- Hietanen & Punamäki, 2006), although no relation-
chotherapy outcome and the working alliance, in ship has been found in other studies (cf. Ligiéro &
which the alliance appears to account for approxi- Gelso, 2002; Reis & Grenyer, 2004).
mately 5% of the variation in client outcome (e.g., In their review of the literature on the psychother-
Wampold, 2001). This effect appears robust and not apy alliance, Castonguay, Constantino, and Holtforth
dependent on factors such as type of psychotherapy, (2006) suggest that one of the next steps in alliance
length of treatment, publication status of the re- research should be the identification of how therapists
search, sample size, outcome measure used, or time balance the use of techniques in therapy while
of alliance assessment (Horvath & Symonds, 1991; developing and maintaining a strong alliance. They
Martin et al., 2000). recommend that a study of expert therapists should
In addition, research on the alliance has been be conducted to further this aim. The current study of
conducted in relation to therapist styles of interac- eminent therapists’ intentionality can help to clarify
tion and techniques. Ackerman and Hilsenroth’s this literature by showing how experts conceptualize

Correspondence concerning this article should be addressed to Heidi M. Levitt, Department of Psychology, 202 Psychology Building,
University of Memphis, Memphis, TN 38152, USA. E-mail: hlevitt@memphis.edu

ISSN 1050-3307 print/ISSN 1468-4381 online # 2010 Society for Psychotherapy Research
DOI: 10.1080/10503300903476708
338 H. M. Levitt and D. C. Williams

their work on the alliance in relation to the generation outcome measures in 85 studies comparing huma-
of new insights and awareness in clients. Toward this nistic psychotherapy with control groups or other
end, it can be useful to first consider the ways approaches (some conducted by humanistic thera-
therapists have described the process of facilitating pists but many by therapists with other allegiances as
changes in client awareness and the empirical re- well). Their content analysis showed that the major-
search on this process. ity of awareness processes identified in a review of
psychotherapy literature were not assessed by any of
the nine measures. These processes included the
Psychotherapeutic Models of Awareness
symbolization of, access to, or expression of new
Across schools of psychotherapy, the development of emotions; the development of new meaning con-
new awareness about one’s internal experiences and nected to internal experience; increased awareness of
interpersonal processes is held to be an important new choices; and interpersonal awareness or aware-
indicator of client growth. Whereas psychodynamic ness of personal growth or insight. Although their
therapists focus on expanding awareness to uncon- review focused on comparisons of humanistic and
scious patterns (e.g., Freud, 1900/1955), cognitive other therapies, eight of the nine measures were
therapists help clients become aware of the effects of developed instead by researchers interested in med-
their thought processing (e.g., Beck, 1976), huma- ical research, cognitivebehavioral therapy (CBT),
nists direct clients’ awareness to unrecognized and family therapy and appeared to be selected by
aspects of their internal experience (e.g., Greenberg, researchers primarily because of their popular usage
Rice, & Elliott, 1993), and feminist or multicultural outside of humanistic approaches.
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therapists assist clients to realize forms of oppression Because outcome measures do not appear to be
in their environments (e.g., Brown, 1994). Although sensitive to changes in awareness, the most common
the scope and focus of awareness may differ, all these way in which clients’ awareness has been examined,
therapies guide clients to expand their awareness, to outside of case study research perhaps, is through
integrate new realizations, and to reevaluate their studies using psychotherapy process measures that
functioning given their evolving understanding. examine in-session changes in awareness. Most of
Indeed, the process of expanding and integrating these process measures study awareness by tracking
awareness can be understood as a common factor forms of awareness within sessions that are impor-
across psychotherapy orientation. Ironically, tant to the therapy orientation of their originators.
although it has received a great deal of attention For instance, the Experiencing Scale (Klein,
within psychotherapy approaches, it is a topic that Mathieu-Coghlan, Gendlin, & Keisler, 1970), devel-
has not received much study across approaches. oped by client-centered therapists, assesses changes
Although it seems that new awareness is thought to within emotion-based awareness. Some measures do
lead to change, there is no consensus on the track types of processing associated with growing
relationship between these factors. For some theor- awareness without seeming to privilege one psy-
ists new awareness or insight is synonymous with chotherapy’s mechanism of change (e.g., Levitt &
change (e.g., Miller & C’de Baca, 2001), whereas for Frankel, 2004; Stiles, 2001). Because these process
others insight alone is insufficient in producing measures are based on fixed forms of awareness,
change (e.g., Gaylin, 2000) and for a third however, they tend to track whether specific types of
group new awareness can only follow change (e.g., awareness are associated with symptom change or
Levenson, 1998). To shed light on this process, we alliance within psychotherapy rather than develop
present data about the intentions that eminent understandings of how therapists act to further
psychotherapists utilize to develop awareness in clients’ awareness more broadly. For instance, a
clients. Although not assessed directly in the present measure that tracks changes in awareness as indi-
study, new awareness, in particular an experience of cated by types of silences does not track how other
difference from the way a problem was experienced forms of awareness might interact with silent aware-
at the beginning of therapy, emerged as a central ness (e.g., Frankel, Levitt, Murray, Greenberg, &
finding, prompting this literature review. Angus, 2006). As such, there is a need for inductive
studies to identify common features in how thera-
pists conceptualize the processes of developing
Empirical Research on the Development of
awareness in therapy and maintaining the alliance.
Awareness in Psychotherapy
In addition to this body of process measure
Psychotherapy outcome measures generally do research, qualitative studies have tracked different
not assess for changes in clients’ awareness. Indeed, shifts in awareness. Qualitative research has found
Levitt, Stanley, Frankel, and Raina (2005) examined that, for most psychotherapies, the process of devel-
the nine most commonly used psychotherapy oping awareness is so implicated in regular practice
Facilitating client change 339

that Rennie’s (1992) grounded theory analysis found case; Williams, 2004), researchers often divide these
the process of reflexive self-examination to be the data into multiple chapters or articles for publica-
core function of psychotherapy*that is, the process tion, each focusing on a distinct set of findings (see
of turning one’s attention upon oneself and engaging Fassinger, 2005). Although prior publications from
in self-exploration and analysis*and Elliott’s (1985) this project have presented findings from data that
cluster analysis found ‘‘new perspective’’ to be focused on participants’ description of the role of
identified as a central task in psychotherapy. Also agency in therapy (Williams & Levitt, 2007a) and on
along this theme, a main finding in Levitt, Butler, the question of negotiating values in psychotherapy
and Hill’s (2006) grounded theory study was that (Williams & Levitt, 2007b), the current report
therapists’ use of their interventions to structure a presents the central findings of the study: how
focus in which reflexivity could occur was experi- therapists across orientations facilitate change in
enced as significant by clients. clients’ awareness while safeguarding the therapeutic
As well, Elliott and colleagues have conducted alliance.
comprehensive process-recall studies in which thera-
pists’, clients’, and third-party observers’ perspec-
Participants
tives have been used to identify microprocesses that
are helpful to clients and through which clients’ Therapists. Interviews were conducted with 14
awareness shifts. They tracked clients’ shift from a experts in the field of psychotherapy practice to
state of negative overgeneralization to the clarifica- explore their understanding of the process of facil-
tion of a problem and the realization of specific itating change. These therapists’ names and their
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needs (Rees et al., 2001), in which therapists help psychotherapy orientations are listed in Table I.
clients to refocus on identifying their positive needs There was limited diversity in terms of gender and
instead of what they are missing. They studied the race, with only one woman and one racial minority
emergence of insight (Elliott et al., 1994), in which participant. Therapists’ orientations are organized in
therapists orient clients toward incorporating novel Table I into meta-orientations as well to allow for the
information and to continue to ponder this informa- identification of the origin of quotes within a type of
tion until it becomes integrated and elaborated. therapy (but without identifying the specific thera-
They also studied the change in clients, from vague pist). Eminent therapists were selected for interview
awareness to acute awareness, and therapists’ use of based on their therapeutic expertise and their in-
suggestion, confrontation, and reframing in that depth study of psychotherapy processes. These
process. This research points to the importance of qualifications can help to select interviewees who
broadening clients’ awareness and its relevance to may be uniquely able to recall and articulate their
therapeutic gains. practices and for a study of optimal practices and
intentions. To be considered an eminent and expert
therapist, participants met at least one of the
Method
following four criteria: having held prestigious posi-
This study has been derived from a larger project tions in divisions or associations related to psy-
examining the process of fostering client change. chotherapy (n 9), having written more than
Because of the substantial data generated in quali- 100 articles on psychotherapy (n 5), having
tative research projects (a 167-page document in this received awards for significant contributions to

Table I. Therapists’ Data

Therapist name Primary psychotherapy approach Meta-orientation classification

Gerald Davison Cognitivebehavioral Cognitivebehavioral


Arthur Freeman Cognitivebehavioral Cognitivebehavioral
Marvin Goldfried Cognitivebehavioral Cognitivebehavioral
Steven Hollon Cognitivebehavioral Cognitivebehavioral
Laura Brown Feminist Constructivist
Bruce Ecker Depth-oriented brief therapy Constructivist
Robert Neimeyer Narrative constructivist Constructivist
Donald Polkinghorne Narrative existential Constructivist
David Rennie Experiential person centered Humanist
Arthur Bohart Humanist Humanist
Leslie Greenberg Experiential Humanist
Morris Eagle Object relational Psychodynamic
Adelbert Jenkins Psychodynamic/psychoanalytic Psychodynamic
Donald Spence Psychodynamic Psychodynamic
340 H. M. Levitt and D. C. Williams

psychotherapy practice or research (n 10), and interviews, only one therapist was still hesitant about
having founded a psychotherapy approach (n 2). his identity being revealed, and he consented to
Many participants met more than one criterion. identity disclosure after reviewing a description of
Furthermore, five participants took part in the the findings.
American Psychological Association’s psychotherapy
demonstration videos, at least five train professionals Interviewing. All interviews, except one that was
in their therapy orientation via workshops, and all audio recorded in person, were recorded via tele-
the participants had more than 20 years of experi- phone and lasted approximately 1 hr. Levitt, who has
ence conducting psychotherapy. These diverse ac- expertise in conducting, publishing, and teaching
complishments suggest that the participants hold qualitative research methods, trained Daniel C.
expert status in both the practice and understanding Williams in qualitative interviewing skills before the
of psychotherapy. commencement of the interviews and then reviewed
each interview to provide feedback to Williams, who
Researchers. The study was designed by Heidi M. conducted the interviews. Interviews were con-
Levitt, Daniel C. Williams was the interviewer, and ducted using an exploratory style of interaction, in
both authors acted as study coanalysts. Both authors which open-ended and nondirectional questions
identify as integrationists, with their practice of were used to restrict the participant biasing. Inter-
therapy most strongly influenced by constructivist viewees were asked to respond to questions based on
and humanist approaches but also by psychody- their personal experience as therapists rather than
namic, feminist, and CBT approaches. Although the providing a description of their therapeutic orienta-
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authors did have an understanding of how therapists tions. They were told that the primary question of
foster client change within different approaches, they the study was ‘‘How do you understand the process
did not have specific expectations about commonal- of change within your own practice of psychother-
ities in process other than that processes of self- apy?’’ An example of a prompt specifically about the
examination might be involved. process of change and the therapeutic relationship
was ‘‘Does the therapeutic relationship facilitate
change? If so, how?’’ No questions explicitly targeted
Procedure the development of awareness; rather, the focus on
Recruitment. We were most concerned with awareness emerged within the inductive analysis as
recruiting therapists of different psychotherapeutic an answer to the question of how the therapists
orientations (see Patton, 1990, on maximal variation facilitated change. Responses about awareness
recruitment), so that the results would reflect themes tended to be given to prompts such as ‘‘What do
across theoretical approaches and interventions used you do to help clients change?’’
in psychotherapy. After the initial recruitment, the
researchers used theoretical sampling (Glaser & Grounded Theory Analysis. Following transcription,
Strauss, 1967), a method in which participants are the interviews were analyzed using grounded theory
recruited specifically to flesh out aspects of a (Glaser & Strauss, 1967), a method at the forefront
preliminary analysis that appear to be inadequately of qualitative psychotherapy research (Ponterotto,
addressed. Participants then were recruited who 2005). This inductive method guides researchers to
could address those aspects, in this case more develop an empirically based model of a phenom-
cognitive therapists to describe their perspective on enon. The version of this method developed by
the change process. Rennie (e.g., 1992) was utilized. This approach is
A total of 28 therapists were contacted and asked congruent with the methodical hermeneutic episte-
to participate in an interview on their experience of mology that he (2000) argued is the appropriate
facilitating change in psychotherapy. Fourteen thera- context for this method. It frames the rigor of
pists declined participation, mostly because of time grounded theory analyses within a constructivist
limitations, resulting in a sample of 14 therapists. framework, in which the formation of precise (and
Because they were being recruited for their posi- often complex) interpretation is prized over objecti-
tions of expertise, participants were asked whether vist criteria, such as the interrater coding of discrete
they would forgo anonymity in this project and allow categories. Note taking, or ‘‘memoing,’’ also was
their identities to be revealed in resultant publica- used to help the researchers become aware of their
tions. Therapists were asked whether they felt own biases, ensure that the analysis was grounded in
comfortable doing so both at the beginning and the data, and record their decisions and theoretical
end of their interviews and were told that they could ideas during the analysis.
also change their decision when they received a Within this approach, the investigators studied the
description of the research findings. At the end of the transcripts and divided them into ‘‘meaning units,’’
Facilitating client change 341

or portions of text that contain a single idea (Giorgi, Credibility Checks


1970). Every meaning unit was assigned a label that
Three credibility checks were utilized to assess the
remained close to the participants’ language. Next,
rigor of the analysis. First, at the end of each
the investigators compared the meaning units and
interview, participants were asked to reflect on
formed categories that grouped units based on
both the content and the interpersonal process of
perceived similarities. Coding of meaning units into
the interview. This process allowed participants to
categories was not exclusive, so that meaning units
share information that otherwise might have been
could be sorted into multiple categories that were
omitted and to provide feedback to the interviewer.
relevant to the meaning they contained. The cate-
gories then were compared with one another and None of the participants reported difficulty in
commonalities between them led to the development sharing responses or had substantial feedback for
of higher order categories. This process of analysis improving the interviews.
continued, resulting in a multilayered hierarchical Second, consensus was reached between the re-
model. At the apex of this hierarchy was the core searchers through the format of weekly meetings to
category: the central interpretation of the data. discuss the analysis for a period of approximately
Within grounded theory, saturation is the point at 1 year, just following the initial wave of data collection
which new data appear to be redundant and new and transcription. Within a qualitative model, con-
categories do not appear to be forthcoming when sensus is thought to increase credibility (Elliott,
new interviews are added into the analysis. In this Fischer, & Rennie, 1999) because it indicates that
study, saturation occurred at the 10th interview, and more than one investigator supports the interpretation
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no new categories emerged at the subcategory level of the data. The interpretations of both researchers
or higher for the four interviews that were added were considered important because Levitt supervised
after this point, suggesting that the data collection the process of interviewing, acted as coanalyst,
was comprehensive. and had more lived experience as a psychotherapist,
and Williams had garnered experience with the inter-
viewing process and the primary analysis.
The Development of Principles about Third, following data analysis, detailed feedback
Psychotherapeutic Process was requested from one participant from each
After completing the grounded theory analysis, the theoretical meta-orientation, leading to the clarifica-
authors, first independently and then collaboratively, tion and refinement of the findings and principles.
conducted a hermeneutic analysis of the hierarchy to The remainder of participants then were sent the
identify principles that could provide direction to revised results and principles and asked to provide
therapy practice (see Levitt, Neimeyer, & Williams, either written or verbal feedback. In total, seven of
2005, for a discussion of the term principles). the participants (50%) provided feedback (including
Hermeneutic methods can be particularly suited the initial four). All responses were positive. None
for forming principles for practice because of their of the participants objected to the analysis or the
attunement to implicit, contextual, and covert fac- developed principles; instead, their feedback offered
tors within data and thus can complement the suggestions on using theory-neutral language,
grounded theory creation of typologies (e.g., Levitt further information to clarify points, or praise for
et al., 2006). the analysis.
Hermeneuts prize lived experiences with a subject
matter because they may assist in the identification Results
of implicit meanings (see Packer & Addison, 1989).
In this case, the researchers bring both their experi- The transcripts were divided into 1,500 meaning
ences with psychotherapy as well as the conducting units. Because meaning units were sometimes as-
and analyzing of these interviews to the hermeneutic signed to multiple categories, the final hierarchy
process. The investigators looked across the cate- included 3,090 meaning units. The hierarchy con-
gories to identify patterns that were used to effect tained 13 layers; however, space limitations preclude
change across therapy orientations. When partici- the description of all these levels. The following
pants’ responses conflicted, either between or within terminology is used to reference the top levels of the
therapists, the context and assumptions within the hierarchy: A single ‘‘core category’’ comprised the
interview text were examined closely to provide top layer, which subsumed six ‘‘clusters.’’ These
guidance on why or under what conditions therapists clusters contained seven ‘‘categories,’’ some of which
might elect one path over another. To make clear encompassed ‘‘subcategories’’ (Table II). This article
their derivation, the principles are presented follow- focuses on the two clusters that described the role of
ing the categories on which they were based. the relationship and the process of change in therapy.
342 H. M. Levitt and D. C. Williams
Table II. Description of Clusters, Categories, and Subcategories

Category Subcategory

Cluster 1: Developing client awareness through (a) stimulating self-curiosity, (b) emotionally engaged exploration, (c) challenging ideas that block
growth, and (d) integrating new symbolization.
1. Curiosity heightens introspection and stimulates a new way of A. Interventions lead to seeking a new framework for understanding
searching for influences
B. Introspection heightens awareness of inner experience and leads
to a search for influences and solutions
2. Emotional exploration increases motivation and application of A. Listening for unspoken subtext facilitates emotional exploration
change
B. An intensely inward focus helps clients to become aware of
emotions that are not fully recognized
C. Therapists’ empathy, honesty, and validation are essential for
emotional exploration
D. Self-understanding motivates clients to grow but they are limited
by anxiety
3. Challenging and interpreting are used when growth is obstructed A. Interpretations prepare for new sense of self and meaning
B. Challenging beliefs leads to reflection on whether belief should be
kept
4. Finding language through own experience and therapist’s sugges- A. Language brings experiences into awareness for exploration
tions to bring into awareness a deeper understanding of experience
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B. Therapist facilitates the articulation of experience using joint


symbolization
Cluster 2: Relationship safety is prioritized to the extent that in-session client risk taking is needed to make change.
1. Therapist disclosure created an intimate relationship when it did A. Therapist disclosure allows for a real and intimate relationship
not disrupt clients’ needs for safety that may disconfirm dysfunctional relationship expectations
B. Cautions that disclosure should not destroy boundaries that
protect clients’ or therapists’ needs
2. Lack of mutual goals can reduce both the safety needed to take A. Mutual goals can be created only when clients have the courage
risks and the possibility of change to engage and therapists work through barriers presented by
therapistclient differences
B. Therapists need to work to understand clients’ goals
3. Relationship skills facilitate client risk taking in session, task skills A. A trustworthy, emotionally open connection must be forged
facilitate change out of session
B. Therapists prioritize their skills and knowledge to accomplish a
task

Cluster 1: Developing Client Awareness psychodynamic, three CBT, three humanist) de-
through (a) Stimulating Self-Curiosity, (b) scribed guiding clients to develop an attitude of
Emotionally Engaged Exploration, (c) curiosity about themselves and to recognize the
Challenging Ideas that Block Growth, and (d) benefits of sustaining a reflexive exploration with
Integrating New Symbolization the aim of broadening awareness.
Within this cluster, patterns were identified within 1.1a: Interventions lead to seeking a new framework
therapists’ descriptions of the intentions and methods for understanding. When asked how he helped clients
that they used to guide client change. In this section, become psychologically minded, a psychodynamic
each category is discussed in turn, providing descrip- therapist replied:
tions based on the subcategories it subsumed. This
cluster contained meaning units from the interviews ‘‘I think you become a little more introspective . . .
of all 14 therapists (four CBT, three humanist, three curiosity is one of the big things here*to be
psychodynamic, four constructivist). curious about what may, for example, trigger road
rage, or overeating . . .With curiosity. . .the key part
1.1: Curiosity Heightens Introspection and Stimulates of it, and [it is] one of the things I try to establish
a New Way of Searching for Influences. In this category, early on, that is, to make him feel like he’s
most therapists (n 13: four constructivist, three collaborating with me, wondering about why
Facilitating client change 343

certain things happen in life, certain thoughts ‘‘I really try to listen to the more delicate nuances
occur.’’ of people’s words. . . .The way in which people
verbally underscore certain words that become
Stimulating introspection was thought to help then quality terms that really can be unpacked in
clients become coinvestigators about their experi- greater detail. When they use language that is
ence and active participants in the therapeutic filled with rich imagery and emotion, then that
process. almost always is a signal of something important
1.1b: Introspection heightens awareness of inner to sort of reflect and explore in more detail’’
experience and leads to a search for influences and (constructivist).
solutions. Although reflexivity itself could be an
important new ability for clients, the development By listening keenly, therapists led clients to learn to
of curiosity about specific areas of functioning (e.g., sustain reflexive emotional exploration, resulting in
one’s resistance) was emphasized as clients moved to refined awarenesses and new frameworks for under-
uncover difficult material: standing.
1.2b: An intensely inward focus helps clients to
‘‘The methods I use . . . all amount to prompting become aware of emotions that are not fully recognized:
the client’s experiential attention to go to places in Because of clients’ difficulty identifying their emo-
the client’s own world of constructs that attention tions, five therapists (three humanist, two construc-
never goes’’ (constructivist). tivist) described implementing methods to help
clients introspect, such as Gendlin’s (1998) focus-
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Nine therapists (two psychodynamic, two CBT, two ing, or repeatedly directing attention internally. A
humanists, three constructivist) described specifi- humanist psychotherapist described how the differ-
cally guiding clients to introspect to find the link entiation of new emotions can lead to a dialogue
between behaviors and their possible causes and to between aspects of self that can transform clients:
examine their subjective experiences. Across
approaches, therapists invited self-curiosity because ‘‘In its most primitive form, if somebody’s feeling
it led clients to recognize that their psychological fear or afraid, or shame, they have action tenden-
processes (whether cognitive, emotional, uncon- cies and meanings about danger and withdrawal.
scious, or interpersonal) played an important role [With] the fear, I’m organized to run away. But if I
in their life experience. The ability to become and feel anger I have an action tendency to thrust
sustain curiosity about oneself appeared to be a forward, I have a whole different self-organization.
requisite of psychotherapeutic change. So if . . .we can get them to a self-organization
The principle derived from this category was: based on the anger and the fear, the anger is going
Therapists tried to stimulate clients to become curious to transform the fear.’’
about themselves, the causes of their problems, and
potential solutions through guided introspection. This As clients became more aware of their emotions,
principle emphasizes the importance of stimulating the therapist explained, they could experience pre-
curiosity at the onset of therapy to motivate clients to viously unrecognized emotions and assume more
develop self-awareness, especially when clients adaptive self-organizations.
lacked this curiosity about themselves, a task often 1.2c: Therapists’ empathy, honesty, and validation
are essential for emotional exploration: Several therapist
neglected in the psychotherapy literature.
qualities were thought to be necessary for this kind
1.2: Emotional Exploration Increases Motivation of introspection. Some of the therapists described
and Application of Change. This next category was respect and validation for the clients’ experience
developed to represent most of the therapists’ (n  (n 7 [two humanist, three constructivist, two
13 [four constructivist, three psychodynamic, three psychodynamic]), honesty and openness (n 7
CBT, three humanist]) emphasis on the role of [two humanist, three psychodynamic, two construc-
emotional experience and empathy in sessions. tivist]), and empathic attunement (n 7 [two CBT,
1.2a: Listening for unspoken subtext facilitates one constructivist, three humanist, one psychody-
emotional exploration: Four therapists (two construc- namic]) as helping clients to engage in the reflexive
tivist, one humanist, one psychodynamic) empha- task of therapy. For instance, a humanist therapist
sized that because clients often do not have the described empathy as ‘‘crucial’’ and described the
language to distinguish and label their emotions, connection between these qualities as he paradoxi-
therapists need to note subtle cues that might signal cally cautioned therapists not to use empathy
an entrée to emotional exploration: instrumentally,
344 H. M. Levitt and D. C. Williams

‘‘In a classical Rogerian approach . . . your goal is seemed blocked in their progress (n 13 [four CBT,
actually to be in contact with the other person in a three humanist, three psychodynamic, three con-
genuine and respectful way. And . . . as part of that, structivist]). Some therapists (n 6 [three CBT, two
you end up being empathic and warm and so on, constructivist, one humanist]) encouraged clients to
but you don’t deliberately use empathy as an sustain curiosity and seek changes in awareness by
intervention. You don’t deliberately try to be challenging problematic beliefs or assumptions via
warm to make some effect happen. What you’re interpretations or guided experiments:
really trying to do is to meet and contact another
person in a receptive, respectful way.’’ ‘‘[I] get them to test out whether or not their own
self-perceptions are as true as they perceive. I get
Although empathy is important, it was not con- them to take a look at whether or not it’s as
sidered valid if it is based upon artifice. Particularly, necessary to be loved by everybody or be as
therapists stressed the importance of the qualities competent in all situations’’ (CBT).
described in this subcategory for emotional explora-
tion and the exploration of vulnerable and anxiety- The CBT therapists tended to describe a process of
ridden themes as clients were thought to require the empirically testing out beliefs outside of sessions as a
security provided by this kind of relationship during central method to teach clients to question whether
these activities. their beliefs fit with their realities.
1.2d: Self-understanding motivates clients to grow The use of interpretations to focus clients’ atten-
but their growth is limited by anxiety: Many of the tion on inconsistent and maladaptive behaviors was
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therapists described the process of change as one in another way that some therapists (n 7 [three CBT,
which clients inherently were motivated to change by two constructivist, two psychodynamic]) acted to
new understandings, but which could be blocked by heighten clients’ reflexivity. Drawing clients’ aware-
anxiety (n 9 [two psychodynamic, two humanist, ness to inconsistencies encouraged them to question
four constructivist, one CBT]). The therapists em- and more closely examine their attitudes and to
phasized that there was comfort in not changing and question maladaptive or harmful behaviors.
that people had reasons for resisting change at times:
‘‘You [the therapist] can’t be wimpy and sort of let
‘‘Within that pulsation, this [resistance] is the time them get away with things that they do with other
for recuperation and for things to come back people that are not getting them anywhere. If they
together again, to get self-organized again before engage in self-defeating behavior, like acting
making the next step to move on’’ (constructivist). inconsiderate . . .you owe it to them to point out
that, ‘Do you do this with other people? Do you do
These therapists respected this cycle of growth and this with your wife*not listen to what they’re
integration. saying?’ . . . . [If] you’re doing this on the outside
At the same time, some therapists described and maybe this has something to do with the
wanting clients to move through anxieties that were difficulty you have communicating with people, or
obstructing their growth. In these cases, therapists getting along with people’’ (CBT).
(n 7 [two psychodynamic, two constructivist, two
humanist, one CBT]) often used the same process to Explicitly attending to clients’ behaviors that
increase clients’ awareness of the content of that obstructed their progress, contradictions, or thought
anxiety and motivate them to grow. By staying with patterns were ways therapists described to teach
and understanding the fears about changing, the clients to become curious and to sustain self-reflection.
therapists described helping clients integrate their These methods helped clients who were trapped in
desire to change with their other desires and come to one way of making sense of their experience and
a new position from which they could move forward. lacked the ability to find a solution themselves.
The principle that stemmed from this category The next principle in this cluster was: When growth
was: Therapists facilitated clients’ reflexive exploration of was blocked by clients’ beliefs or capacities for processing,
a pattern of experiences while helping them to recognize, therapists offered interpretations or direct challenges. This
understand, and integrate relevant emotions. This principle addressed the rationale and timing of
principle emphasized the importance of exploring challenges and interpretations by explicating how
vulnerable emotion even within different reflexive expert therapists used directive interventions to
interventions in therapy. support clients.
1.3: Challenging and Interpreting Are Used When 1.4: Finding Language through Own Experience
Growth Is Obstructed. Most of the therapists described and Therapist’s Suggestions to Bring into Awareness a
using more directive interventions when clients Deeper Understanding of Experience. The fourth category
Facilitating client change 345

focused on the role of new symbolization in the therapy These metaphors might come from exploration in
session. It was endorsed by seven therapists, whose therapy but also from books, films, or other contexts
background spanned the major orientations (two that give meaning to clients’ personal experiences.
psychodynamic, two humanist, two constructivist, The final principle of this cluster was: Therapists
one CBT). guided clients to attend to their internal experience
1.4a: Language brings experiences into awareness and find precise representational language to increase
for exploration: The process of description and awareness and understanding. This principle reflects
verbal symbolization was thought to bring experi- that, across therapy orientation, the role of narration
ences, or aspects of experiences, into awareness, to and symbolization appears to be recognized by
make them ‘‘real,’’ and to help hold ideas in eminent therapists as a tool to guide clients to better
mind for reflexive analysis. A CBT therapist dis- access and explore their experiences.
cussed symbolization as a facilitator of changing
awareness. Cluster 2: Relationship Safety is Prioritized to
the Extent that In-session Client Risk Taking is
‘‘It [putting experience into words] takes what is
Needed to Make Change
going on internally that might be confused and
poorly articulated, ‘internally’ meaning ‘within All of the therapists’ interviews contributed units to
their thinking’*either explicit or implicit, and has this cluster that explored the therapists’ thoughts
it externalized [so] that it becomes something about the relationship within therapy.
that they hear themselves saying as opposed to
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thinking about. And when they try to put things 2.1: Therapist Disclosure Created an Intimate
in words, that seems to help them get better Relationship When It Did Not Disrupt Clients’ Needs for
awareness.’’ Safety. The first category was composed of units from
most of the interviewees (n11 [four CBT, three
Helping clients articulate their obscure and inchoate psychodynamic, two humanist, two constructivist]).
emotions was thought to lead to a better under-
standing of their experience. Seven therapists (two 2.1a: Therapist disclosure allows for a real and
humanist, two constructivist, two psychodynamic, intimate relationship that may disconfirm dysfunctional
one CBT) contributed to this subcategory. relationship expectations. Therapists (n 11 [two
1.4b: Therapist facilitates the articulation of humanist, four CBT, two constructivist, three psy-
experience using joint symbolization: Many therapists chodynamic]) indicated that they disclosed their
(n 7 [two psychodynamic, two humanist, two thoughts and feelings to clients in order to develop
constructivist, one CBT]) emphasized the co- a genuine relationship in which clients would feel
constructive process through which new language comfortable enough to openly discuss their pro-
emerges. A method of joint symbolization offered blems. These therapists described how disclosure
helped neutralize the power differential in therapy,
by a few therapists (n 3 [one humanist, one
facilitating this openness.
psychodynamic, one constructivist]) was to invite
the in-session exploration and elaboration of
‘‘I talk about my marriage, my kids, my Mother,
metaphors initiated by either client or therapist. my Dad*anything that seems relevant. I tell
A psychodynamic therapist offered the following stories . . . . [It can] be very comforting for them,
example: because they do tend to worship us . . . . I think it’s
crucially important that the client know that the
‘‘A patient came in and talked about a pattern of
therapist is an ordinary human being and has and
always quitting jobs . . .After a few months of
is struggling, that life is not easy’’ (humanist).
therapy, he suddenly made the comment. He
said, ‘You know, it occurred to me . . . that my These therapists thought that their disclosure would
problem*this quitting my job*is a metaphor for normalize the process of struggle and help clients
what I have done in all my relationships through- avoid heroic expectations of therapists. In addition,
out my life. I quit my friends, I quit relationships.’ the two psychodynamic therapists emphasized that
So the whole thing got expanded to the question of honesty can disconfirm past dysfunctional relation-
why can’t I stick with a commitment I make. . . . ships by providing corrective experiences:
[Finding a metaphor,] it’s a particular way of
seeing it that captures in a way the essence of what ‘‘Almost like a practice arena*to relate to some-
they [different aspects of life] all have in common, one in a way that’s different than the way you’ve
these different situations.’’ been relating a good part of your life*honestly,
346 H. M. Levitt and D. C. Williams

openly, etc. That does require that the therapist be 2.2a: Mutual goals can be created only when clients
authentic and real.’’ have the courage to engage and therapists work through
the barriers presented by therapistclient differences. One
2.1b: Cautions that disclosure should not destroy domain in which most therapists (n 12 [four
boundaries that protect clients’ or therapists’ needs. Some constructivist, three psychodynamic, three CBT,
of the therapists (n 5 [three CBT, one constructi- two humanist]) believed that they must develop
vist, one psychodynamic]) expressed concern that mutual understanding with their clients was the
disclosure could go too far. The CBT therapists setting of therapeutic goals. These therapists stressed
appeared most concerned about setting up a relation- that clients needed the courage to believe that
ship that did not structure professional interactions change was possible in order to take risks in working
and could lead to later misunderstandings. The other toward their goals. Clients’ unwillingness to be
two therapists emphasized that disclosure could lead vulnerable to risk inhibited the therapists from
to closeness or distance depending on the needs of the developing an understanding about their clients’
client. Although it was seen to be generally positive, difficulties and impeded progress. The therapists
therapists’ disclosure could be harmful if the relation- then needed to be able to meet clients where they
ship became unprofessional or if clients felt they were were in their capacities.
less significant to the therapist or less safe in the
session. ‘‘If we respectfully observe those obstacles and
These boundaries could be important for thera- allow our clients to speak from them instead of
pists’ sake as well. trying to override them, I think they become
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avenues toward therapeutic gains’’ (constructi-


‘‘If someone asks about my sex life, I say, ‘That’s vist).
my privacy boundary. This is part of how I model
to you that everyone gets to say, ‘No.’ And let’s Through exploring clients’ barriers, therapists de-
talk about how frustrating it is and how confusing scribed allowing clients to develop strategies that fit
it is for you that there are some things about which better within their lives and to reach greater insights
I am perfectly willing to be direct and some things about their functioning.
that are my privacy boundaries, that’s what Therapists described language, personal, and
privacy boundaries are’’ (constructivist). cultural differences as potential barriers to under-
standing. Without mutually intelligible communica-
By asserting boundaries around personal informa- tion about clients’ problems, it could be difficult to
tion, therapists also attempted to control potential direct the therapy. They stressed the importance of
transference that could compromise the treatment, talking through these barriers with clients to better
respected their own privacy, and encouraged cli- understand their goals and limitations.
ents to implement healthy boundaries in their own 2.2b: Therapists need to work to understand clients’
lives. goals. Many therapists (n 8 [three humanist, two
The following principle was developed to repre- CBT, three constructivist]) acknowledged that goals
sent eminent therapists’ view of disclosure: Therapists needed to be reviewed periodically, and consensus
tended to disclose to develop an honest relationship that should be reached on both the goals of therapy and
promoted change, unless they thought it might impair the process. When disagreements occurred, thera-
progress by blurring therapistclient boundaries, in which pists were seen as having the responsibility to try to
case they would be more withholding. This principle better understand their clients’ perspective. In these
provides a rationale for both when, and when not, to instances, therapists described admitting to clients
disclose that recognizes both the therapists’ and that they didn’t understand their position, asking
clients’ boundary needs. clients to help them better comprehend the reasons
for their goals or their preferences in the therapeutic
2.2: Lack of Mutual Goals Can Reduce Both the process, and working carefully so as to respect the
Safety Needed to Take Risks and the Possibility of clients’ goals, with the caveat that these goals did not
Change. The second category suggested that the entail serious harm to oneself or others.
quality of the therapeutic relationship was experi- The principle developed from this category was:
enced as diminished when clients and therapists Expert therapists tended to adopt their clients’ goals
were not able to develop a common understanding unless these goals interfered or stopped therapeutic pro-
of the goals and processes of therapy. All the gress (e.g., a self-destructive goal), in which case
therapists contributed to this category (N 14 therapists challenged clients to engage in a process of
[four CBT, three psychodynamic, three humanist, critically examining their goals. Implicit in this princi-
four constructivist]). ple is the idea that therapists should continue to
Facilitating client change 347

assess clients’ goals as they evolve across the course Some therapists (n 3 [two humanist, one con-
of therapy. structivist]) emphasized that this relationship re-
quired consistent monitoring.
2.3: Relationship Skills Facilitate Client Risk Taking
‘‘Most important is interpersonal sensitivity . . .You
in Session, Task Skills Facilitate Change out of Session.
say something to somebody and then see how they
The third category focused on the decisions thera-
react and then change what you do or take
pists made about the relative importance of creating into account the feedback so you are in this
a safe environment in which clients could take constant moment-by-moment interactional pro-
emotional risks (N 14 [four constructivist, four cess’’ (humanist).
CBT, three humanist, three psychodynamic]). The
creation of a relationship that could permit and By constantly adjusting according to clients’ needs,
motivate clients to engage in therapeutic tasks, in or these therapists strove to maintain the attunement
out of session, was key. necessary to support client risk taking.
2.3a: A trustworthy, emotionally open connection Two psychodynamic therapists discussed how their
emphasis on the relationship has led them to become
must be forged. All therapists indicated that, at least at
progressively less focused on techniques with clients.
certain times, attention should be placed on building
the therapeutic relationship. The need for safety ‘‘In terms of general style it’s become less and less
appeared to be the chief rationale for the develop- important to have some ‘professional’ role and I
ment of a strong relationship, a view articulated by a
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feel much more natural and relaxed like I would be


constructivist therapist: with anyone else. So in a funny way, I’ve become
less and less interested in specific techniques’’
‘‘My job is to create the safety in which people can
(psychodynamic).
take those risks, to create an environment in which
they can come in and get mad at me and know The deemphasis of technique, these therapists
that . . .it won’t even hurt the relationship.’’ believed, allowed them to develop relationships that
felt more genuine with clients.
Because client risk taking was of such importance, a
therapeutic relationship that could withstand conflict 2.3b: Therapists prioritize their skills and knowledge
and tension had to be created. to accomplish a task. In contrast to the first category,
As described in the last cluster, qualities such as wherein therapists emphasized the need for safety in
honesty, empathy, validation, and respect were the relationship to enable the joint exploration of
thought to be central to this relationship. resistances and development of new interactional
patterns, some therapists emphasized using their
‘‘Unless there is a nontrivial level of respect skills and knowledge to implement a task over their
between both parties, then nothing useful hap- concern with the relationship. This second category
pens. Because the client will not accord a thera- of this cluster described those times (n 7 [three
pist, he or she doesn’t respect sufficient status to CBT, three constructivist, one humanist]).
make a difference in his or her life. And unless we For example, a few therapists emphasized the
deeply respect our clients, I don’t think they will’’ importance of utilizing their scientific knowledge
(constructivist). and skills (n 3 [two CBT, one constructivist]).

Therapists (n 4 [two constructivist; two psychody- ‘‘The goal is to bring the fruits of science to bear
on the issues that people have’’ (CBT).
namic]) also emphasized the importance of helping
clients feel accepted as they are, both to allow clients
These same therapists described their effectiveness
to openly express their personal and intimate details
as dependent on the knowledge of treatments that
of their lives and to risk changing them. are empirically supported:
A few therapists (N3 [two psychodynamic, one
humanist]) conveyed that one way to facilitate ther- ‘‘There are some models that are intuitively
apeutic safety was to present their thoughts in tentative reasonable, but have no empirical support . . .
ways to clients, allowing them to accept, reject, or Kohlberg’s model of morality has great empirical
modify the ideas. Although declarative statements support, so I believe that model. Why? Because I
were thought to feel like challenges to clients, hesitant believe that things should be empirically suppor-
expressions could invite clients to collaborate with ted...That’s why I’ve chosen to do cognitive
therapists and to initiate an inward search for answers. behavior therapy’’ (CBT).
348 H. M. Levitt and D. C. Williams

These therapists tended to stress a process of clients’ progress and shifting their attention to the
evaluating empirical evidence over idiographic feed- component that is next needed to continue the
back from each client. process of change. Although the core category was
It was important for these therapists to maintain a formed from the analysis of all the clusters and some
professional relationship, in which intervention- were not presented in this report, the clusters
based skills and knowledge were of central impor- presented here were instrumental in the creation of
tance: this core category. The first cluster presented here
contributed heavily toward the first (see Category
‘‘It’s a useful thing to be able to operate in ways 1.1), second (see Category 1.2), and fourth (see
that somebody can have some sense of trust that Categories 1.3 and 1.4) stages within the core
you’re not going to mess things up or treat them in category. The third and fifth stages were based
a rude or inappropriate way, and beyond that largely on the analysis of the second cluster and
I don’t think it’s [the relationship is] particularly conceptualizing how change might be generated
important. I think it’s about as important as. . . through the different paths described. In the Dis-
when I go to see the guy who does my taxes, or cussion section, we develop an understanding of the
when I go see the lady who cuts my hair. So I like processes identified in this category and how they
getting along with people, and I think it’s helpful if might be understood and utilized.
you can do that, but I’m particularly interested if
they know what they’re doing’’ (CBT).
Discussion
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When therapists viewed their role as experts who This study offers a unique contribution because it
convey information and teach skills, they appeared has generated findings and principles that have
to deemphasize the therapeutic relationship as the garnered consensus from eminent therapists across
locus of change. Because there was less risk involved orientations to represent the ways they conceptualize
in skill learning, a heightened sensitivity to the the process of psychotherapy. Because it targets the
relationship did not appear as necessary as in this level of therapist intentionality (as opposed to
group of therapists. specific behaviors), it allows readers a window into
To help therapists negotiate the tension between the motivations of these therapists. Together with
attending to the relationship or structuring interven- other findings on therapists’ experience (Williams &
tions, the following principle was developed: To the Levitt, 2007a,2007b) and a companion study, which
extent to which eminent therapists used approaches in interviewed clients on their experience of change
which progress was dependent upon clients’ in-session (Levitt et al., 2006), this research identifies sets of
vulnerability and risk taking, they prioritized the common intentions across therapy approaches.
therapeutic relationship over task-focused interventions. A limitation of this study is a lack of diversity
When the relationship was didactic in nature, however, among our participants, who are primarily White
the intervention received greater priority because in- male therapists. Despite repeated attempts, we had
session risk taking was not the central mechanism of difficulty recruiting many ethnically diverse or
change. This principle was formed to shed light on female therapists who fit the criteria. The analyses
why therapy orientations might emphasize the of the two minority therapists’ interviews, however,
relationship and the intervention differently and to did not suggest that they used unique approaches in
develop an understanding of why differences might facilitating the psychotherapy process. Still, it might
make sense. be useful in future research to specifically assess
whether minority therapists evidence differences in
Core Category. The analysis of the entire hierarchy intentionality in therapy. A second limitation is that,
led to the development of the following core because this study focused on therapists’ intention-
category: The moment-to-moment process of guid- ality, further research reviewing tapes of therapy
ing psychotherapy is one of (a) stimulating curiosity would be needed if one wanted to enumerate the
to (b) sustain exploration within distressing experi- ways therapists might enact the different intentions
ential states for (c) the purpose of generating described.
experiences of difference, (d) stimulating reflexive In terms of strengths, the study design was strong,
symbolization, and (e) providing the structure to utilized multiple credibility checks, and achieved
allow for the integration of these differences (see saturation, suggesting that the analysis was compre-
Williams & Levitt, 2007a, for a discussion of how hensive (see Elliott et al., 1999, on qualitative de-
this core category relates to the management of signs). Also, the sample was rich in variability across
therapists’ values in therapy). This category con- theoretical orientation, which was the form of diver-
tained five components, with therapists monitoring sity of central concern. There were participants from
Facilitating client change 349

each of the dominant psychotherapy orientations language, clients were thought to gain greater access
who identified exclusively within that orientation as to that experience (a concept perhaps most devel-
well as a number who identified as integrationists. oped in the literature on narrative therapy; see Angus
& McLeod, 2004) and could integrate it through
The Story of Psychotherapeutic Change. Although further discourse and come to rely on it in under-
many studies suggest that certain behaviors in standing themselves and forming expectations of the
therapy may be helpful or problematic (e.g., Acker- future.
man & Hilsenroth, 2001), the core findings from this Following their review of the alliance literature,
study suggest that eminent therapists conceptualize Castonguay, Constantino, and Holtforth (2006)
the work of therapy as following a certain plot. argue that future research needs to better help
Although general questions were asked about the therapists learn to negotiate emergent problems
effects of the therapeutic relationship on the change with the alliance. Although most of the analysis
process, this plot largely emerged from the inductive and the attendant principles were formed on the
analysis of data on the therapists’ reports of creating basis of interviews of therapists from all the major
change rather than from any a priori or leading orientations, there appeared to be some differences
questions about curiosity, changes in client aware- in how the alliance was negotiated in the face of task
ness, or experiences of difference. These findings go demands that fell along the lines of psychotherapy
beyond an explication of any one therapeutic or- orientation. An understanding of this difference can
ientation to identify common intentions that appeared help therapists in their practice of psychotherapy and
to be held by therapists across orientations and of in training. Notably, there appeared to be more of an
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how differences in intentions influenced the therapy. emphasis on relationship processes from the huma-
There appeared to be five main elements in this nist, psychodynamic, and constructivist therapists
plotline. First, the therapists helped clients to develop and more of an emphasis on the structuring of tasks
curiosity about themselves so they could become from the CBT therapists. Hence, there are two
motivated to engage in the tasks of therapy. Second, subplots in the story of psychotherapy change.
this curiosity allowed them to sustain a reflexive Although both were attempting to shape experi-
exploration into vulnerable and emotionally charged ences of difference, the client-centered psychody-
topics, which could be anxiety provoking (see Rennie, namic and constructivist therapists worked to have
1992, on the central role of reflexivity in therapy). the most vulnerable aspects of that experience
Although there is remarkably little writing on the unfold within sessions. For this reason, the need to
role of clients’ curiosity in the psychotherapy litera- attend to the relationship was crucial because
ture (see Levitt et al., 2009), there is a good deal of therapists needed to help clients sustain interperso-
work on the utility of exploring difficult emotions in nal exploration. These therapists tended to contri-
psychotherapy that these findings support (e.g., bute the most heavily to the categories about
Greenberg & Pascuale-Leone, 2006; Purzner, therapists’ empathy and validation (1.2c), attending
1988). Third, clients were described as requiring to vulnerable and resistant emotions (1.2a, 1.2b,
increased structure (e.g., through guided exploration 1.2d), symbolization (1.4a, 1.4b), emotional con-
or interventions) and/or support (e.g., a sense of safety nection (2.3a), and the prioritizing of relational
and being valued) as needed in relation to their level sensitivity and tentative language (2.3a), all key
of risk. These findings lend empirical support to processes to facilitate in-session exploration of sensi-
Arkowitz’s (1997) argument that therapies share a tive material (see Lambert & Barley, 2001, on the
commonality in offering sets of interventions and a impact of therapeutic relationship on outcome).
relational context that support client development. In contrast, CBT therapists tended to describe
Fourth, the therapists guided clients toward encoun- structuring tasks that enabled a similar experience of
ters with threatening experiences and the develop- risk to occur out of the session. They contributed most
ment of not only new intellectualized ideas but often to the categories that focused on the need for
actual experiences of difference (see Bohart, 1993, for clear boundaries in therapy (2.1b), challenging
a discussion of the term experiencing in therapy). clients’ beliefs (1.3), and the discussion of therapy
These experiences were based on the recognition or as based on imparting skills and knowledge and
analysis of a previously inaccessible aspect of their having a scientific basis (2.3b). They encouraged
selves (e.g., a cognitive, emotional, social, or inter- clients to engage in exercises such as experiments
personal aspect) that became available within a and thought records, in which clients placed them-
sustained reflexive analysis. This new experience of selves in new situations or mind-sets outside the
a problem could influence associated emotional, therapy context (see Bennett-Levy, 2003, for evi-
intellectual, and relational aspects. Fifth, then, by dence on the effectiveness of experiments and
symbolizing this new experience in metaphors and thought records in cognitive therapies). As a result,
350 H. M. Levitt and D. C. Williams

the CBT clients might be aided most by the Also, because the principles are intentional, their
authority of the therapist (bolstered by their scien- utility is dependent on the therapists’ assessment of
tific knowledge) and their knowledge of how to the situation and context, which could change based
structure and motivate out-of-session tasks that on the clients’ presentation. To capture this assess-
could generate safe experiences of difference without ment process, the principles of the study were
requiring the same vulnerability in the presence of designed to reflect decisional points and explicate
the therapist. In contrast, the other therapists’ focus the judgments that led therapists to adopt one
on developing a relationship to support in-session direction or another. For instance, some principles
vulnerability might be necessary to facilitate a invite therapists to assess whether the clients’ goals
change process that unfolded largely in the presence are self-destructive or not or to assess when clients
of the therapist. are not capable of taking the next step without
Although both sets of therapists described attend- increased guidance. By explicating these decisional
ing to the relationship and giving homework assign- points, the principles can help to sensitize readers to
ments, their emphasis appeared to differ with their what eminent therapists described as central clinical
route toward generating experiences of difference. decisions and to maximize the clinical utility and
For instance, the CBT therapists more frequently sensitivity of their own practice decisions.
emphasized structuring effective tasks, challenging Some of the specific principles put forward ideas
clients, and questioning their goals, all of which that are rarely discussed in the psychotherapy
might assist in generating new experiences out of literature (e.g., the role of curiosity) or formulations
session, whereas the other therapists tended to that explicate the motivations behind interventions
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emphasize the need for a therapeutic relationship (e.g., when the therapists adopted clients’ goals and
in generating in-session change. This distinction in when they did not). The set of principles is a
approach to treatment appeared to be less sharp for contribution because it represents a set of common
therapists who held integrative approaches. This intentions at the heart of psychotherapy practice.
framework of a shared story with subplots, however, They have received the support of the eminent
can aid in conceptualizing common processes under- therapists from across approaches, one of whom
lying different therapies. This understanding also conveyed that he was already using the principles to
draws attention to concepts that are discussed less aid in his training and supervision. In addition,
often in the psychotherapy literature, such as curi- positioning intentionality as the site of psychother-
osity, and draws attention to a common experience apy integration (as opposed to interventions or tasks)
of difference underlying various therapy orientations, can allow for increased coherence within attempts at
potentially a productive area of future research. As integration and mitigate concerns about epistemo-
well, it suggests that there is some utility in focusing logical conflicts in integration (e.g., Neimeyer,
on common intentions in addition to common 1993).
factors across therapies. As well, this hierarchy and the subsequent princi-
ples suggest topics for continued psychotherapy
process and outcome research. For instance, instead
A Common Intention unto All. This analysis identi- of researching a single therapist or client behavior,
fied common intentions that eminent therapists the intentions identified in this study could be
utilized to effect change in therapy and sets of explored by developing process measures that track
principles that reflect steps within this process. By a variety of behaviors associated with specific thera-
focusing on intentionality instead of behavior, we pist aims or by tracking the five steps identified as
avoid implying that all the participants’ practices in constituting common pathways by which therapists
therapy would appear identical but suggest that good work toward change while using different orienta-
therapists appear to have intentions that motivate tions. Because psychotherapy orientation does not
them to lead clients through similar internal change appear to account for much of the variance in client
processes that may have quite different outward change (e.g., Wampold, 2001), there is a need to
manifestations. For instance, therapists might help develop new sets of independent variables from
stimulate clients’ experience of curiosity about their which to structure future research programs. This
experience via a homework exercise, an in-session study suggests one method of approaching this
gestalt chairing exercise, hypnosis, or a multitude problem: Qualitative analyses can investigate psy-
of other interventions. Because the principles are chotherapy as an intentional and contextualized
based within intentionality, they allow therapists- process in order to develop clinically relevant prin-
in-practice to consider their intentions in relation to ciples that provide a platform for future research on
their own therapy approach rather than within any common processes that appear to contribute mean-
single approach to psychotherapy practice. ingfully across psychotherapy orientations.
Facilitating client change 351

Acknowledgements Gendlin, E. T. (1998). Focusing-oriented psychotherapy. A manual of


the experiential method. New York: Guilford Press.
The authors would like to express their appreciation Giorgi, A. (1970). Psychology as a human science: A phenomen-
to Robert Neimeyer and Sara Bridges for their ologically based approach. New York: Harper & Row.
thoughtful feedback on previous drafts of this article Glaser, B. G., & Strauss, A. (1967). Discovery of grounded theory.
Strategies for qualitative research. Chicago: Aldine.
and would like to thank the therapists who donated
Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in
their time as participants. psychotherapy: A practice-friendly research review. Journal of
Clinical Psychology, 62, 611630.
Greenberg, L. S., Rice, L., & Elliott, R. (1993). Facilitating
emotional change: The moment-by-moment process. New York:
References
Guilford Press.
Abouguendia, M., Joyce, A. S., Piper, W. E., & Ogrodniczuk, J. S. Hietanen, O. M., & Punamäki, R. L. (2006). Attachment and
(2004). Alliance as a mediator of expectancy effects in short- early working alliance in adult psychiatric inpatients. Journal of
term group psychotherapy. Group Dynamics, 8, 312. Mental Health, 15, 423435.
Ackerman, S. J., & Hilsenroth, M. J. (2001). A review of therapist Horvath, A. O., & Symonds, B. D. (1991). Relation between
characteristics and techniques negatively impacting on the working alliance and outcome in psychotherapy: A meta-
therapeutic alliance. Psychotherapy, 38, 171185. analysis. Journal of Counseling Psychology, 28, 139149.
Angus, L. A., & McLeod, J. (Eds). (2004). The handbook of Klein, M. H., Mathieu-Coghlan, P. L., Gendlin, E., & Kiesler, D.
narrative and psychotherapy: Practice, theory and research. Thou- J. (1970). The Experiencing Scale: A research and training manual.
sand Oaks, CA: Sage. Madison: Wisconsin Psychiatric Institute.
Arkowitz, H. (1997). The varieties of support in psychotherapy. Lambert, M. J., & Barley, D. E. (2001). Research summary on the
Journal of Psychotherapy Integration, 7, 151159. therapeutic relationship and psychotherapy outcome. Psy-
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. chotherapy: Theory, Research, Practice, Training, 38, 357361.
Downloaded By: [informa internal users] At: 09:04 28 April 2010

New York: International Universities Press. Levenson, E. (1998). Awareness, insight and change. Contempor-
Bennett-Levy, J. (2003). Mechanisms of change in cognitive ary Psychoanalysis, 34, 239249.
therapy: The case of automatic thought records and beha- Levitt, H. M., Butler, M., & Hill, T. (2006). What clients find
vioural experiments. Behavioural and Cognitive Psychotherapy, helpful in psychotherapy: Principles for facilitating change.
31, 261277. Journal of Counseling Psychology, 53, 314324.
Black, S., Hardy, G., Turpin, G., & Parry, G. (2005). Self- Levitt, H. M., & Frankel, Z. (2004). Pausing Inventory Classifica-
reported attachment styles and therapeutic orientation of tion System (PICS) manual (2nd rev.). Unpublished manu-
therapists and their relationship with reported general alliance script, University of Memphis.
quality and problems in therapy. Psychology and Psychotherapy: Levitt, H. M., Neimeyer, R. A., & Williams, D. C. (2005). Rules
Theory, Research and Practice, 78, 363377. vs. principles in psychotherapy: Implications of the quest for
Bohart, A. C. (1993). Experiencing: The basis of psychotherapy.
universal guidelines in the movement for empirically supported
Journal of Psychotherapy Integration, 3, 5167.
treatments. Journal of Contemporary Psychotherapy, 35, 117129.
Brown, L. S. (1994). Subversive dialogues: Theory in feminist
Levitt, H. M., Stanley, C. M., Frankel, Z., & Raina, K. (2005). An
therapy. New York: Basic Books.
evaluation of outcome measures used in humanistic psy-
Castonguay, L. G., Constantino, M. J., & Holtforth, M. G.
chotherapy research: Using thermometers to weigh oranges.
(2006). The working alliance: Where are we and where should
The Humanistic Psychologist, 33(2), 113130.
we go? Psychotherapy: Theory, Research, Practice, Training, 43,
Levitt, H. M., Williams, D. C., Cifci-Uruk, A., Kannan, D.,
271279.
Obana, M., Smith, B., et al. (2009). The experience of abiding
Elliott, R. (1985). Helpful and nonhelpful events in brief
curiosity: The pursuit of congruence despite the danger of
counseling interviews: An empirical taxonomy. Journal of
Counseling Psychology, 32, 307322. engulfment. Journal of Constructivist Psychology, 22, 187212.
Elliott, R., Fischer, C. T., & Rennie, D. L. (1999). Evolving Ligiéro, D. P., & Gelso, C. J. (2002). Countertransference,
guidelines for publication of qualitative research studies in attachment, and the working alliance: The therapist’s contribu-
psychology and related fields. British Journal of Clinical Psychol- tion. Psychotherapy: Theory, Research, Practice, Training, 39,
ogy, 38, 215229. 311.
Elliott, R., Shapiro, D. A., Firth-Cozens, J., Stiles, W. B., Hardy, Martin, D. J., Garske, J. P., & Davis, K. M. (2000). Relation of the
G. E., Llewelyn, S. P., et al. (1994). Comprehensive process therapeutic alliance with outcome and other variables: A meta-
analysis of insight events in cognitive-behavioral and psycho- analytic review. Journal of Consulting and Clinical Psychology, 68,
dynamic-interpersonal psychotherapies. Psychotherapy Research, 438450.
41, 449463. Miller, W., & C’de Baca, J. (2001). Quantum change: When
Fassinger, R. E. (2005). Paradigms, praxis, problems and epiphanies and sudden insights transform ordinary lives. New
promise: Grounded theory research in counseling psychology. York: Guilford Press.
Journal of Counseling Psychology, 52, 156166. Neimeyer, R. A. (1993). Constructivism and the problem of
Frankel, Z., Levitt, H., Murray, D., Greenberg, L., & Angus, L. psychotherapy integration. Journal of Psychotherapy Integration,
(2006). Assessing silent processes in psychotherapy: An em- 3(2), 133157.
pirically derived categorization system and sampling strategy. Packer, M. J., & Addison, R. B. (Eds). (1989). Entering the circle:
Psychotherapy Research, 16, 627638. Hermeneutic investigation in psychology. Albany: State University
Freud, S. (1955). The interpretation of dreams. In J. Strachey of New York Press.
(Ed. and Trans.), The standard edition of the complete psycholo- Patton, M. Q. (1990). Qualitative evaluation and research methods.
gical works of Sigmund Freud (Vols. 45). London: Hogarth Newbury Park, CA: Sage.
Press. (Original work published 1900) Ponterotto, J. G. (2005). Qualitative research training in counsel-
Gaylin, W. (2000). Talk is not enough: How psychotherapy really ing psychology: A survey of directors of training. Teaching of
works. New York: Little, Brown. Psychology, 32, 6062.
352 H. M. Levitt and D. C. Williams
Purzner, K. (1988). Psychoanalysis as therapeutic crisis induction: Rennie, D. L. (2000). Grounded theory methodology as metho-
Affect and emotion as a prerequisite of radical change. dical hermeneutics: Reconciling realism and relativism. Theory
Psychopathology, 21, 143148. & Psychology, 10, 481502.
Rees, A., Gillian, H. E., Barkham, M., Elliott, R., Smith, J. A., & Stiles, W. (2001). Assimilation of problematic experiences.
Reynolds, S. (2001). ‘‘It’s like catching a desire before it flies Psychotherapy: Theory, Research, Practice. Training, 38(4),
away’’: A comprehensive process analysis of a problem clar- 462465.
ification event in cognitive-behavioral therapy for depression. Wampold, B. E. (2001). The great psychotherapy debate: Models,
Psychotherapy Research, 11, 331351. methods, and findings. Mahwah, NJ: Erlbaum.
Reis, S., & Grenyer, B. F. S. (2004). Fearful attachment, Williams, D. C. (2004). Therapists’ perspectives on the process of
working alliance and treatment response for individuals with change in psychotherapy. Unpublished master’s thesis, University
major depression. Clinical Psychology & Psychotherapy, 11, 414 of Memphis.
424. Williams, D. C., & Levitt, H. M. (2007a). Principles for
Rennie, D. L. (1992). Qualitative analysis of the client’s experi- facilitating agency in psychotherapy. Psychotherapy Research,
ence of psychotherapy: The unfolding of reflexivity. In S. 17(1), 6682.
Toukmanian & D. Rennie (Eds), Psychotherapy process research: Williams, D. C., & Levitt, H. M. (2007b). A question of values:
Paradigmatic and narrative approaches (pp. 211233). Newbury Developing principles for change. Journal of Psychotherapy
Park, CA: Sage. Integration, 17, 159184.
Downloaded By: [informa internal users] At: 09:04 28 April 2010

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