Embed Size (px)
Citation preview
This article was downloaded by: [The University of Manchester Library]On: 15 October 2014, At: 13:47Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK
Psychotherapy ResearchPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/tpsr20
Client relationship incidents in early therapy:Doorways to collaborative engagementMarilyn R. Fitzpatrick a , Jennifer Janzen b , Martha Chamodraka a , Susan Gamberg a &Emily Blake aa Department of Educational & Counselling Psychology , McGill University , Montrealb Institute of Community and Family Psychiatry , Jewish General Hospital , Montreal,Quebec, CanadaPublished online: 19 Oct 2009.
To cite this article: Marilyn R. Fitzpatrick , Jennifer Janzen , Martha Chamodraka , Susan Gamberg & Emily Blake (2009)Client relationship incidents in early therapy: Doorways to collaborative engagement, Psychotherapy Research, 19:6,654-665, DOI: 10.1080/10503300902878235
To link to this article: http://dx.doi.org/10.1080/10503300902878235
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Client relationship incidents in early therapy: Doorwaysto collaborative engagement
MARILYN R. FITZPATRICK1, JENNIFER JANZEN2, MARTHA CHAMODRAKA1,
SUSAN GAMBERG1, & EMILY BLAKE1
1Department of Educational & Counselling Psychology, McGill University, Montreal & 2Institute of Community and Family
Psychiatry, Jewish General Hospital, Montreal, Quebec, Canada
(Received 11 March 2008; revised 6 March 2009; accepted 7 March 2009)
AbstractThe purpose of this study was to elaborate how clients understand the development of the alliance and to highlight aspectsof the process particular to depressed clients working with experienced therapists. Fifteen participants described criticalincidents in early therapy that influenced how they understood their working relationships with therapists. All incidentsinvolved clients appraising what their therapists were doing. Through interviewer probing, participants were able to identifythe importance of their own activity (disclosing and working with therapist input) as their collaboration in the incidents.Positive emotional responses were woven through the descriptions of the incidents. The research underscores how clientunderstanding of collaboration might be accessed by researchers or clinicians and the potential importance of the interactionof client active exploration with positive emotions in understanding alliance development.
Keywords: alliance; critical incident; client engagement; positive emotion; openness; involvement; client perspective
In the context of research linking the quality of early
alliance to outcome (Martin, Garske, & Davis, 2000)
and the current importance of relational factors
across most theories of therapy (Samstag, 2006), it
is essential to understand the processes that create
the therapeutic relationship. Recent emphasis on
clarifying the construct of alliance (see Psychother-
apy: Theory, Research, Practice, Training, 2006, spe-
cial edition) is an essential aspect of articulating
these processes. However, we continue to need more
nuanced understandings of the client point of view
(Tryon, Blackwell, & Hamel, 2007).
This research elaborates how clients understand
the formation of the alliance by extending a previous
investigation of client perspectives on critical inci-
dents in alliance development (Fitzpatrick, Janzen,
Chamodraka, & Park, 2006). The previous investi-
gation was conducted with novice counselors who
worked with relatively healthy clients. The current
study with depressed clients and more experienced
therapists was developed to highlight possible differ-
ences due to client distress and therapist experience
and to locate similarities that transcended the client
and therapist differences. We begin with a review of
research related to how clients understand their
working relationships in therapy.
Client Understanding of the Alliance
Collaborative work is a key feature of many theore-
tical discussions of alliance. Hatcher and Barends’s
(2006) elaboration of Bordin’s (1979) alliance con-
ceptualization underscores the importance of client
participation in the actualization of the alliance in
session. These authors note that when the client is
engaged in purposive work, the alliance is strong.
Techniques are used in an effort to engage clients in
therapeutic work. Although both therapists and
clients are contributing to the alliance development,
recent investigations of client perspectives have
emphasized the importance that clients place on
therapists in this process (Bedi, 2006; Bedi, Davis, &
Williams, 2005; Fitzpatrick et al., 2006). In a recent
concept mapping of client-identified alliance devel-
opment factors, 10 of the 11 categories identified
were the responsibility of the therapist (Bedi, 2006).
In addition, therapist contributions were the core
element of critical events that clients described as
Correspondence concerning this article should be addressed to Marilyn R. Fitzpatrick, Department of Educational & Counselling
Psychology, McGill University, 3700 McTavish Street, Montreal, Quebec H3A 1Y2, Canada. E-mail: [email protected]
Psychotherapy Research, November 2009; 19(6): 654�665
ISSN 1050-3307 print/ISSN 1468-4381 online # 2009 Society for Psychotherapy Research
DOI: 10.1080/10503300902878235
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
contributing to their working relationships (Fitzpa-
trick et al., 2006). Should this be interpreted to
mean that clients place the responsibility for alliance
development on therapists?
Bedi (2006) concluded from his work that clients
do not affirm the importance of their own contribu-
tion to alliance formation. Hatcher and Barends
(2006) have offered an alternative explanation. They
suggest that like ‘‘the fictional character who did not
identify that he had been speaking in prose all his
life’’ (p. 295), clients do not readily identify what
they are doing as collaboration or notice their own
contribution to the alliance. However, if clients are
participating, is it necessary for them to be aware of
this? Understanding how their participation impacts
the process may have therapeutic benefits for clients.
Research has indicated that clients who are prepared
with information, including the need to be open, to
self-disclose, and to take a more active role, have
more positive attitudes to treatment (Acosta, Yama-
moto, Evans, & Skilbeck, 1983), drop out less
frequently (Reis & Brown, 2006), and experience
greater symptom reduction (Zwick & Attkisson,
1985). The fact that clients may not readily notice
their collaboration means that researchers who
investigate it may need to focus participants’ atten-
tion on it.
We would not expect clients in early treatment to
be thinking much about therapeutic collaboration.
Clients come to treatment because they are dis-
tressed. Client distress has been relatively neglected
in the alliance literature, which has tended to focus
on less severely impaired clients (Horvath & Bedi,
2002), leaving gaps in our understanding of alliance
development processes. Because one of the most
common sources of client distress is depression, we
elected to study depressed clients.
Depressed Clients’ and Experienced
Therapists’ Contributions to Alliance
Development
The current investigation investigated depressed
clients working with experienced therapists. The
purpose of this work was to extend a previous
investigation of critical incidents in early alliance
development nominated by a group of relatively
healthy clients working with novice counselors
(Fitzpatrick et al., 2006). Critical incidents research
is an approach that aims to capture moments in the
therapeutic processes that substantially influence the
process and outcome of therapy (Elliott, 1984;
Timulak & Elliott, 2003). Moments identified as
having helpful impacts offer an important window
into valued therapeutic processes (see Timulak,
2007, for a review).
In Fitzpatrick et al. (2006), critical incidents
nominated by clients were characterized by in-
creased exploration. However, the distress levels of
clients in that study were moderate (M �6.2, SD �2.8, on a distress scale of 1�13 using Battle et al.’s,
1966, Target Complaints [TC] instrument). We
wondered whether depressed clients would also
form alliances in this way. In particular, we ques-
tioned whether the loss of interest and pleasure in
activity and the difficulties in concentration that are
cardinal symptoms of depression might interfere
with exploratory involvement in early sessions
when symptoms would tend to be most severe.
Research has indicated the importance of early
alliance with depressed clients. Depressed clients
with better alliances have a more rapid decline in
symptoms (Zuroff & Blatt, 2006) and the impact of
alliance moderates the relationship between insecure
attachment and outcome, causing the effect of a
secure interpersonal style to become insignificant
with depressed patients (Saatsi, Hardy, & Cahill,
2007). Although the role of alliance is clearly
important, it remains unknown how depressed
clients form their alliances.
We also wondered whether clients working with
more experienced therapists might react differently
than those working with novices. Studies investigat-
ing therapist experience and alliance have produced
equivocal findings (e.g., Dunkle & Friedlander,
1996; Mallinckrodt & Nelson, 1991), indicating
that there is likely a complex relationship between
experience and alliance. Summers and Barber
(2003) have suggested a way of understanding that
complexity; experienced therapists may be more
competent in recognizing appropriate treatment
goals and tasks than novices. Research has shown
that elite practitioners of family therapy are more
able to focus, or place, their attention (Holmes,
2008). Although elite and experienced practitioners
are not necessarily the same, collaboration on
identifying tasks and goals is central to how alliance
is currently understood (two of the three subscales of
Horvath & Greenberg’s, 1986, widely used Working
Alliance Inventory measure collaboration on tasks
and goals). Comparing client reactions to experi-
enced and novice therapists could shed light on the
complexity of the experience�alliance relationship.
The study reported here addresses the question of
how depressed clients working with experienced
therapists understand alliance development using a
critical events method. We also compare the per-
spectives from these clients with those of a group of
nondepressed clients working with less experienced
therapists (Fitzpatrick et al., 2006). The comparison
was conducted according to guidelines for the
cumulative assessment of qualitative findings that
Client relationship incidents 655
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
facilitate comparisons of similar work in order to
develop a more comprehensive perspective and to
highlight contradictory findings (Timulak, 2007, in
press). Because alliance forms early in treatment
(Sexton, Hembre, & Kvarme, 1996), the current
investigation and the Fitzpatrick et al. (2006) study
both focus on incidents that occurred within the first
three sessions of treatment.
Method
Participants
Clients. Participants were 15 clients (12 women, 3
men) ranging in age from 20 to 61 years (M�27.2,
SD�11.18). They identified their origins as Cauca-
sian (n�8), Canadian (n�2), Persian/Iranian
(n�1), Armenian (n�1), Southeast Asian (n�1),
Chinese/Mauritian (n�1); one participant did not
respond to this question. All clients presented with a
primary complaint of depression, and 14 of the 15
clients scored within the clinical range for depression
on the Symptom Checklist-90-Revised (SCL-90-R;
Derogatis, 1977; M�71.9, SD�6.4); one client
failed to complete the measure. The discomfort
associated with the presenting problems as measured
by the TC instrument (Battle et al., 1966) ranged
from 4 to 13 (M�10, SD�2.08). A comparison
with the distress levels of Fitzpatrick et al. (2006);
d�1.54; Cohen, 1988) indicated that the sample in
the current study had substantially greater distress
about their presenting complaints.
Therapists. Therapists were 10 counselors (seven
women, three men) at two different urban university
counseling centers in eastern Canada. They ranged
in age from 29 to 57 years (M�47.2, SD�9.1) and
had been in full-time practice from 3 to 25 years
after the completion of their degree (M�8.7, SD�6.2). The therapists in Fitzpatrick et al. (2006) were
completing a first practicum in an MA counseling
psychology program.
All therapists were Caucasian. Five therapists saw
two clients each. Most therapists identified their
therapeutic orientations as mixtures of the following:
humanistic (n�6), cognitive�behavioural (n�3),
psychodynamic (n�3), feminist (n�1), narrative
(n�1).
Coding team. The primary coding team consisted of
a 27-year-old female doctoral student with 4 years of
counseling experience and an experiential�psychodynamic orientation, a 24-year-old female
doctoral student with 3 years of counseling experience
and an integrative orientation, and a 30-year-old
female doctoral student with 2 years of counseling
experience and an experiential�interpersonal ap-
proach. The auditor was a 31-year-old female doc-
toral student with 5 years of clinical experience, who
identified her orientation as psychodynamic. Final
coding was also audited by a woman, an experiential�dynamic professor with 22 years of counseling experi-
ence. One member of the coding team and both
auditors had previously participated in consensual
qualitative research (CQR) studies; the other team
member was trained by the experienced group mem-
bers.
Measures
Target complaints (Battle et al., 1966). To describe
the level of distress associated with the presenting
problem, we used the TC Severity scale, a self-report
measure that assesses severity on a scale ranging
from not at all (1) to couldn’t be worse (13). The scale
measures global improvement and has been highly
correlated with other measures of outcome.
Symptom Checklist-90-R Depression subscale
(Derogatis, 1977). The SCL-90-R Depression sub-
scale was used to assess depression. The Depression
subscale is composed of 15 problems causing
distress during the past 7 days (including today).
Each item is rated on a 5-point scale of distress,
ranging from not at all (0) to extremely (4). Char-
acteristic depression problems include ‘‘Feeling
lonely,’’ ‘‘Worrying too much about things,’’ ‘‘Feeling
no interest in things,’’ ‘‘Feelings of worthlessness.’’
The SCL-90-R has high internal consistency (.77�.90) and test�retest reliability (.78�.90; Derogatis,
1977). Validation studies of the SCL-90-R indicate
excellent agreement between the hypothetical and
empirical definitions of depression (Derogatis &
Cleary, 1977).
Interview. A semistructured interview protocol,
developed by Fitzpatrick et al. (2006) and designed
to examine clients’ perspectives on alliance, was
used. Because alliance is not a term that is normally
used or understood by clients, we referred in the
interviews to the working relationship with the thera-
pist. The term was chosen after clients in a pilot test
of the interview protocol understood the simpler
term relationship to suggest that they had some kind
of nonprofessional, extratherapy contact with their
therapists. The adjective ‘‘working’’ was designed to
capture the agreement on tasks and goals aspects of
the alliance, and ‘‘relationship’’ was thought to
represent the commonly held idea of rapport or
bond. The interview was completed directly after the
third session. First, we asked clients to characterize
their working relationship. If the characterization
656 M. R. Fitzpatrick et al.
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
was positive, the interviewer asked the participants
to describe how they knew the relationship was ‘‘on
the right track’’; if the characterization was negative,
they were asked to describe ‘‘what got in the way of
the relationship getting going.’’ Participants were
asked to describe in detail a critical incident or the
best example of what they had characterized that was
particularly poignant, important, or meaningful to
them. Participants were also prompted to comment
on their own and the therapist’s contribution to the
incident.
Procedures
Procedures were identical to those used by Fitzpa-
trick et al. (2006) except for the recruitment of
depressed clients. The research was approved by the
ethical review boards of the two participating uni-
versities. Potential participants were interviewed to
assess for depression by the intake professional
(counselor or psychologist) at their university coun-
seling centers. Those who were assessed as suffering
from major depression based on Diagnostic and
Statistical Manual of Mental Disorders (fourth edition,
text revision; American Psychiatric Association,
2000) criteria were asked whether they would be
willing to participate in a study ‘‘to help us learn
more about how counseling works.’’ The first 15
clients to consent who could be assigned to a
participating therapist received and completed a
research package before beginning therapy. The
package included the consent form, a demographics
form, the TC, and the SCL-90-R. The interviews
were conducted after the third session of therapy and
lasted from 40 to 55 min. All clients who met the
intake criteria and consented were interviewed.
Therapists whose clients participated in the study
provided demographic information, including their
years of experience.
Data Analysis
The data were analyzed according to the CQR
method (Hill et al., 2005; Hill, Thompson, & Nutt
Williams, 1997). CQR has been found to be suitable
for in-depth studies of participants’ inner experi-
ences such as memories of a critical incident; it is a
rigorous approach that reduces the biases of using a
single researcher (Hill et al., 2005).
Domain coding and auditing. The CQR method
allows the researcher to begin with a ‘‘start list’’ of
broadly defined domains based on an understanding
of the field and to revise those domains according to
the data (Hill et al., 2005). Because the interviews
were conducted with the same protocol as Fitzpatrick
et al. (2006), the domains from that study were used
as the start list. Final definitions of domains and
selection and definition of categories were guided
exclusively by the data. The initial domain list
included (a) Description of the Critical Incident,
(b) Client Contribution to the Incident, (c) Meaning
of the Incident to the Client, (d) Impact of Incident
on the Relationship, and (e) General Outcome of the
Incident. During the coding process, the team added
one new domain: Comparison to Previous Therapy.
In addition, they changed the name of one domain:
Impact of Incident on the Relationship became
Emotional Impact of Incident on the Relationship.
Core ideas coding and auditing. Core ideas are the
essence of the participants’ thoughts in more concise
language. Core ideas were extracted from interview
transcripts independently by each person on the
three-member coding team and then discussed until
consensus was reached on concept and wording.
Team members regularly consulted the transcripts to
ensure that essential details were included and client
meanings maintained in the coding process. The
auditor reviewed the consensus version of the
analysis and made suggestions for alternative word-
ing; these were reviewed and generally incorporated
into the core ideas’ coding.
Cross-case analysis and auditing. The coding team
then examined the core ideas across cases and
created categories, the more abstracted representa-
tions of the core ideas. The team then met to develop
a consensus version of the categories, returning to
the transcripts as necessary to ensure that data were
accurately represented. The auditor compared the
consensus version with the core ideas and made
suggestions for changes. The coding team reviewed
and compared the auditors’ work and accepted most
auditing suggestions. Following the cross-case audit,
Marilyn R. Fitzpatrick reviewed all results and made
one suggestion for a new domain: Impact of Previous
Therapy Experience. In the process of writing the
article and explaining the coding, the team contin-
ued to return to any domain or core idea that could
not be well explained or justified. As a result, one
core idea in the General Outcome of the Incident
domain was dropped and another was moved from
this domain to the Emotional Impact of Incident on
the Relationship domain. We used the three-cate-
gory CQR system to present the findings. General
findings applied to all or all but one case (i.e., 12�13
cases), typical findings to more than half of cases
(i.e., 7�11 cases), and variant findings to between
two and six cases.
Client relationship incidents 657
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
Comparison of Studies
After completing the analysis of the data for the
current study, we proceeded to compare it to
Fitzpatrick et al. (2006). Timulak (2007, in press)
has discussed processes for conducting rigorous
secondary analyses of primary qualitative findings.
Although no single process is universally applicable,
all methods rely on flexible qualitative data analytical
strategies to abstract commonalities and to take into
account discrepant findings. We used the first three
steps of Timulak’s four-step descriptive-interpreta-
tive conceptual framework to frame our data analytic
comparison: (a) developing domains, (b) delineating
meaning units, (c) categorization and comparison of
different meaning units. The final step, assessing the
influence of methodological issues, is presented
within the discussion.
Developing domains. According to Timulak (in
press), qualitative meta-analysis requires a tentative
conceptual framework for organizing data. This
conceptual framework may be provisionally drafted
by the researchers, or the researchers may decide to
use a framework from one of the primary studies.
Because the domains from Fitzpatrick et al. (2006)
were the start list for the current study, we began
with that framework for the comparison.
Delineating meaning units. Meaning units are the
smallest units of data that convey meaning without
contextual information. In the secondary analysis,
meaning units usually consist of the primary studies’
categories and their descriptions (Timulak, in press).
The meaning units for the comparison were the
categories and their descriptions from both studies.
Illustrative quotes and vignettes were also consulted
to clarify meaning units.
Categorization and comparison of different meaning
units. Once the data are divided into meaning units
(categories) within particular domains, researchers
organize them according to similarities in their
meanings as provided by the definitions and exam-
ples. Individual meaning units are inspected, and
the essence of the meaning contained in each of
them is put into words to encompass both unique
and common meanings. Although some categories
are self-explanatory, others may be supplemented
with brief descriptions (Timulak, in press). We first
examined the definitions of the categories from the
primary studies and the examples of those categories
for similarities in meaning using definitions and
paradigmatic examples. Where existing category
names adequately represented data from both stu-
dies, these were retained. New category names and
definitions were developed when existing names did
not adequately represent both studies.
Results
Two of the 15 participants described negative
incidents in their relationship development; 13
described positive incidents. Because two interviews
did not allow us to arrive at a trustworthy under-
standing of negative incidents from which to draw
conclusions, these cases were excluded from the
main analysis. A short summary of the two negative
cases is presented at the end of this section for the
information of researchers who may wish to investi-
gate negative alliance development more fully. Next,
we describe each domain and the definitions or
parameters for the categories within the domains for
the 13 positive cases. Table I presents the domains,
the categories within each domain in descending
order of frequency, and the incidence (general,
typical, or variant) of each category. In naming the
categories, we chose the term client to reflect the fact
that the data refer to the relationships that were
present in the sessions; when discussing data from
the interviews in the text, these individuals are
referred to as participants. We give examples of the
core ideas within each category and provide illus-
trative quotes or vignettes.
Domains
Description of the critical incident. The interview
asked participants to characterize and describe their
working relationship with the therapist and then to
narrate specific incidents that exemplified their
descriptions. Seven different categories of critical
incidents were coded in the Description of the
Critical Incident domain. All categories within this
domain focused on what the therapist did to develop
the working relationship. The first category was
typical; all other categories were coded as variant.
The first category*‘‘Therapist helped client think
or act in a new way’’*included events in which
therapists either showed ways to deal with a problem
by giving advice and suggestions or made links for
their clients. One participant said, ‘‘We talked about
something and she related it to something in my life
that I had already told her and it was . . .a connection
that I had never made.’’ The second type of critical
incident occurred when the ‘‘Therapist gave special
attention.’’ Here, participants noticed things that
therapists did that showed them that the therapist
was really interested in them as people. Included
here were therapeutic strategies such as remember-
ing details from a previous session or being curious
about why a client had not wanted to attend the
658 M. R. Fitzpatrick et al.
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
session that day. One participant described how her
therapist had noticed a reference to her in a
magazine before the participant herself had seen
the article. The third type of incident involved
situations in which the ‘‘Therapist provided emo-
tional support.’’ Clinicians did this by validating and
normalizing participant feelings and by offering
encouragement about participant capabilities. One
participant reported how her therapist told her that
there was no reason for her to feel she was not
capable and reassured her that she could handle
whatever happened. There were also critical inci-
dents in which the ‘‘Therapist communicated under-
standing.’’ These incidents included narratives that
emphasized how therapists explained or clarified
client meanings. ‘‘Sometimes when you’re just trying
to get everything out but you can’t really put into a
sentence what your saying, and then she’s . . .almost
like my translator for me.’’
Another category focused on incidents in which
the ‘‘Therapist met client’s unexpressed needs’’ by
picking up on something that the participant wanted
and offering it. ‘‘We were looking at diagrams . . . and
I thought, ‘Well*I can do this at home . . . I want
you to come over my shoulder’ . . . and there was the
chair, she came over.’’ In the incidents in which the
‘‘Therapist did not judge,’’ therapists were accepting
of things where clients expected disapproval or
dissatisfaction. In one case, the therapist did not
focus extensively on the fact that the participant
forgot to bring her homework to the session. Another
participant explained, ‘‘Just because on that specific
day I’m not having a grand crisis, just because I’m
not suicidal . . . doesn’t mean that it’s not impor-
tant.’’
Meaning of the incident to the client. Whereas the
Description of the Critical Incident domain captured
therapist behaviors during the incidents, the Mean-
ing of the Incident to the Client domain focused on
how participants understood or interpreted what had
happened. The most frequently occurring core idea
was ‘‘Therapist cares.’’ This category focused on the
therapist treating the participant as someone impor-
tant and worthy of help, ‘‘not just a number’’ or ‘‘not
just her 4 o’clock person.’’ In the category ‘‘Thera-
pist understands,’’ participants focused on their
belief that their therapists caught their ideas or
knew how they needed to work. ‘‘His knowing how
I’m feeling and how I’m working . . . it feels good that
he . . . understands this.’’
The only meaning of an incident that did not focus
on the therapist was ‘‘Client gains a new under-
standing of personal experience.’’ Here, participants
focused more on what happened to them: recogniz-
ing something new, making a new connection, or
having a new understanding of the relationship.
‘‘That was really helpful, that felt like a really big
breakthrough because up to that point, like I had no
clue how to stop it or where it was coming from.’’
When participants felt that the meaning of the
incident was that the ‘‘Therapist really listens,’’
Table I. Domains, Categories, and Frequencies of Categories of Critical Incidents
Domain Category Frequency
Description of Critical Incident Therapist helped client think or act in a new way Typical
Therapist demonstrated interest Variant
Therapist provided emotional support Variant
Therapist communicated understanding Variant
Therapist met client’s unexpressed needs Variant
Therapist did not judge Variant
Meaning of the Incident Therapist cares Typical
Therapist understands Variant
Client gains new understanding of personal experience Variant
Therapist really listens Variant
Therapist is skilled Variant
Client Contribution to the Incident Client is open with the therapist Typical
Client works actively Variant
Comparison to previous therapy Comparing the therapy process Variant
Comparing the therapist Variant
Emotional Impact of the Incident Client feels understood Typical
Client feels comfortable Typical
General outcome of the Incident Increased self-assurance/decrease anxiety Variant
Increased positive expectations Variant
Increased client openness Variant
Note. Categories are presented in descending order of frequency within each domain. General �12�13 cases, typical �7�11 cases, variant �2�6 cases.
Client relationship incidents 659
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
they were moved by how their therapist remembered
things and thought about them. One participant
noted that the quality of the interventions made her
feel confident that the therapist had really been
listening. The final meaning of the incidents was that
the ‘‘Therapist is skilled.’’ This referred to a number
of different kinds of skills that participants felt
indicated that therapists understood the process
and were doing it well. One participant described
how her therapist gave her solutions that she had
tried and that worked for her and then noted that the
incident meant that the therapist knew what he was
doing.
Client contribution to the incident. Participants were
also asked what they believed they had contributed
to the incidents. Within the Client Contribution to
the Incident domain, two categories were identified:
‘‘Client is open with the therapist’’ and ‘‘Client
works actively.’’ Most frequently, participants iden-
tified their openness and readiness for disclosure.
They described how they revealed central issues or
talked about difficult things. One participant con-
fessed to her therapist with some chagrin that she
had not wanted to come to her session that day. The
second participant contribution, ‘‘Client works ac-
tively,’’ was categorized when participants empha-
sized how they worked with ideas that came up in
session or continued to work between sessions. In-
session behaviors included working to conceptualize
and understand issues. ‘‘I related it to my past
feelings for my stepmother . . . I was making a link
in that session . . . about my current relationships and
my past relationships and what affect it had.’’ Out-
of-session behaviors included following through on
therapist suggestions or homework.
Comparison to previous therapy. Although the inter-
viewers did not ask, almost half of the participants
spontaneously drew comparisons between their cur-
rent working relationship and a relationship with a
previous therapist. When they had been unhappy
with their previous therapy, participants spoke about
appreciating the differences. If participants had been
satisfied with the previous therapy, participants
spoke about similarities to the current sessions. We
did not code these data in the Client Contribution to
the Incident domain because none of the partici-
pants explicitly identified this activity as a contribu-
tion to the session or the process.
Two categories emerged in this domain: ‘‘Com-
paring the therapy process’’ and ‘‘Comparing the
therapist.’’ Process comparisons were coded when
participants evaluated the usefulness of what was
happening in sessions in contrast to their previous
experiences. One participant indicated that her
former treatment had been unsuccessful because
she had focused on blaming the therapist for a lack of
progress; with this therapist, she was determined to
do the work in order to see the results. In the
personal comparison cases, participants compared
the personal qualities (e.g., warmth, openness) of the
current therapist with those of a previous therapist.
Emotional impact of incident on the relationship. All
participants had positive emotional responses to the
critical incident. While the data in the Meaning of
the Incident to the Client domain focused on how
clients explained what had happened, this domain
captured the affective responses of participants and
their implications for the ongoing relationship. The
word ‘‘emotional’’ was used to capture participants’
emphasis on the affect experienced. Positive emo-
tional reactions were evident throughout the narra-
tives in tone and in content, although references to
emotion per se were usually brief. We identified two
categories in this domain (both typical) that cap-
tured the emotionally toned effects of the incidents.
In the category ‘‘Client feels confidently under-
stood,’’ participants emphasized how their confi-
dence increased or they experienced a sense of
relief, encouragement, or hopefulness because their
therapist was able to grasp their situation and
difficulties: ‘‘It was encouraging in the sense of,
again on that level, she was understanding what’s
going on.’’ We coded ‘‘Client feels comfortable’’
when participants used words like ‘‘relaxed,’’ ‘‘less
worried,’’ and most frequently ‘‘comfortable’’ to
describe their general emotional reactions to being
with the therapist after the incidents.
General outcome of the incident. This domain
described the therapeutic process that resulted
from the incident. Whereas the Emotional Impact
of the Incident on the Relationship domain focused
on how the incidents elicited an affective response,
this domain reflected the influence of the incident on
the work. In the first category ‘‘Increased self-
assurance/decreased anxiety,’’ participants described
the incidents that led to increased self-assurance or
decreased anxiety with their therapists: ‘‘So, I don’t
know what he’s actually thinking . . .at first I thought
it was a bad thing . . . I was a little worried about that.
But then I realized that that I don’t need him . . . to
really validate me.’’ Participants also reported ‘‘In-
creased positive expectations.’’ In this category, they
described the development of a positive outlook for
the sessions based on increased confidence in the
process or the sense that therapy would be helpful.
One participant responded to an incident with this
enthusiastic positive expectation: ‘‘I came back the
next session and I said, ‘You know, I’ve been
660 M. R. Fitzpatrick et al.
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
thinking about this a lot’ and . . . like I really look
forward to these sessions.’’ A third category in the
outcome domain was ‘‘Increased client openness.’’
Here, participants focused on how the incident
resulted in them saying more or censoring less. For
one participant, the incident helped her to realize the
ways in which she had been holding back in previous
sessions.
Negative cases. Both of the negative cases involved
situations in which the participant wanted more
from the therapist but was unable to express that
desire. One expected extra time that the therapist did
not give and concluded that the therapist was just
another person who was too busy for her. This
participant was angry, withheld important informa-
tion in the session, and wondered whether her
therapist even liked her. The other participant hoped
that the therapist would talk more, although he felt
he could not ask for this. He had not been talking
about what was really bothering him and felt that the
therapist misunderstood what he wanted. He con-
cluded that the therapist was cold and uninvolved
and that he would have to do this on his own.
Comparison of the Two Studies
One of the purposes of qualitative comparison is to
highlight similarities and differences. We compared
the results of the current study with Fitzpatrick et al.
(2006). The process of the comparison involved (a)
development of domains, (b) delineation of meaning
units, and (c) categorization and comparison of the
different meaning units. Because this type of com-
parison tends to comprise a large number of
categories, one solution is to present data in table
form (Timulak, in press). Table II presents the
details of the comparison. Where categories were
similar across investigations, they are presented side
by side in the middle and right-hand columns; the
comparison category is in the left-hand column.
Codes that are unique to either study are presented
alone in the column of the relevant study.
Developing domains. We retained four of the five
domains from Fitzpatrick et al. (2006) where the
definitions were very similar to the current study.
The domain title Impact of the Incident on the
Relationship from the current study was chosen
because there was also an emotional quality to the
impacts in Fitzpatrick et al. (2006). One new
domain, Comparison to Previous Therapist, was
unique to the current study.
Delineating meaning units. Both categories and
subcategories along with the examples and quota-
tions provided in the text were the meaning units
that comprised the data for the comparison study.
Categorizing and comparing meaning units. For the
domain Description of the Critical Incident, we
developed four comparison categories: Two cate-
gories in the current study and one in Fitzpatrick et
al. (2006) were unique. The Meaning of Incident to
the Client domain had the least overlap of any
domain; only two comparison categories were iden-
tified. Within the Client Contribution to the Inci-
dent and the Emotional Impact of the Incident on
the Relationship domains, two comparison cate-
gories for each domain encompassed all data from
both studies. For the General Outcome of the
Incident domain, we combined the three categories
from each study to form two comparison categories.
Discussion
The kinds of interventions that clients noticed their
experienced therapists performing (facilitating new
thoughts or actions, providing support, communi-
cating understanding, and remaining nonjudgmen-
tal) were consistent with the types of interventions
(exploration, support, understanding) and personal
qualities (openness) that Ackerman and Hilsenroth
(2003) found contribute positively to the alliance.
Another alliance-enhancing intervention noted by
these authors was attending to patient experience. In
both studies, clients referred to interventions that
offered them something that they found special or
something they had wished for, a wish that was often
unspoken to the therapist. The therapists were
attending to the clients’ experiences closely enough
to offer theses prized interventions. These data bring
into focus how clients can perceive our attention to
their experience, how it represents something special
to them and draws them into the working relation-
ship. Although we did not collect enough negative
incidents to make firm conclusions, the two negative
incidents identified offer a poignant counterpoint to
this idea: Both involved clients’ unexpressed wishes
to which their therapists did not attend.
Consistent with previous research (Bedi, 2006;
Bedi et al., 2005; Fitzpatrick et al., 2006; Mohr &
Woodhouse, 2001), participant descriptions of alli-
ance fostering incidents focused on therapists’ inter-
ventions and not their own actions. Bedi (2006)
interpreted as evidence that the collaborative dimen-
sions of alliance that feature prominently in theore-
tical and professional discussions are unimportant to
clients. However, the current findings as well as
those of Fitzpatrick et al. (2006) indicate that
productive self-disclosure and active receptivity
Client relationship incidents 661
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
were recognized by clients as their participation in
the development of the relationship.
One explanation for the relative lack of emphasis
on client collaboration in other studies (e.g., Bache-
lor, 1995; Bedi, 2006; Bedi et al., 2005) is the
different approaches to coding that are inevitable
when different teams conduct qualitative analyses.
For example, in Bedi (2006), the statement ‘‘I
expanded upon issues brought up in counseling or
my feelings about issues’’ was coded as education; in
the current study, it would have been coded as client
activity. A more encompassing explanation for the
difference may be the different interview or ques-
tionnaire protocols. Bedi (2006) asked clients for
observable behaviors that formed or strengthened
the working relationship. Bachelor (1995) asked
participants to write about the relationship (what
happened, what was said, and what they felt). In
Fitzpatrick et al. (2006) and the current study,
researchers probed for information about client
contributions if participants did not spontaneously
offer it.
Early in the therapeutic process, attributing re-
sponsibility to the therapist is understandable.
Before coming to therapy, most clients have
struggled unsuccessfully to handle their problems
Table II. Comparative Analysis of Domains and Categories
Comparison study Current study Fitzpatrick et al. (2006)
Description of Critical Incident
Therapist helped client think or think in a
act in a new way
Therapist helped client think or act in a new
way
Therapist helped clientnew way (intriguing
question; new perspective; observation of
patterns)
Therapist gave tools or assignment
Therapist was supportive Therapist provided emotional support Therapist shared something meaningful
(compliment/ reassurance/positive feedback)
Therapist gave something special Therapist gave special attention Therapist shared something meaningful (self-
disclosure)
Therapist responded to client wish Therapist met client’s unexpressed need Therapist responded to client wish
Therapist communicated
understanding to client
Therapist did not judge as client feared
Therapist encouraged client to take space
(allowed client expression; invited
collaboration)
Meaning of Incident for the Client
Therapist caring means I’m important Therapist cares I’m important; I’m the center
Therapist’s skill will help me Therapist is skilled Therapist understands
Client gained a
new understanding of personal experience
My therapist can help me
Therapist really listens
I’m okay I can do this myself too Now I know
what to do here
Client Contribution to the Incident
Productive self-disclosure Client is open with the therapist Productive openness
Client works actively Bidirectional openness
Active receptivity Client works actively (on therapist
suggestions) Bidirectional openness
Comparison to Previous
Therapy Comparing the therapy process
Comparing the therapist
Receptive openness
Emotional Impact of the Incident on the
Relationship
Client confidence Client feels confidently understood Trust or confidence in the therapist
Trust or confidence in the process
Acceptance and validation
Client comfort and safety Client feels comfortable General Outcome of
the Incident
Comfort and safety
Increase in positive outlook Increased positive expectations Increase in positive emotion/positive
expectation
Increased self assurance/decrease anxiety
Increase in exploration Increased client openness Increase in disclosure/openness
Increase in client productivity
Note. Where categories are part of the same comparison code, they are presented side by side. Unique categories are presented in their own
rows.
662 M. R. Fitzpatrick et al.
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
on their own. With prompting, however, all partici-
pants were able to articulate how their willingness to
openly discuss their issues or their receptivity to
therapist input contributed to the incidents. They
understood their contribution but did not readily
think of it. We would characterize this as ‘‘demon-
strating in action their understanding of and agree-
ment with the tasks of therapy’’ (Hatcher & Barends,
2006, p. 295). To access how clients understood
their collaboration, however, researchers probably
need to explicitly ask about it.
While researchers interested in collaboration need
to prompt clients to talk about it, should therapists
do something similar? Research has indicated that
when clients have pretherapy preparation informing
them about the importance of their openness, self-
disclosure, and active role, they have more positive
attitudes to treatment (Acosta et al., 1983), drop out
less frequently (Reis & Brown, 2006), and experi-
ence greater symptom reduction (Zwick, & Attkis-
son, 1985). Although clients in the current study
were aware of their contributions, interviewers
needed to focus on this issue in order to obtain
fuller descriptions. Similarly, therapists may do well
to prompt clients to focus on their own contributions
in order to obtain the benefits associated with
pretherapy preparation. Drawing their attention to
the importance of what they are already doing might
foster hopeful and positive feelings in early sessions.
The Interaction of Positive Emotion
and Exploration
Positive emotions were highly salient in these data;
all positive incidents nominated by both depressed
and healthier clients had positively toned emotional
impacts. In comparing the outcomes of the inci-
dents, however, we notice differences in emphasis
between the depressed and the healthy clients. The
depressed clients focused more frequently on in-
creases in self-assurance and positive expectations,
decreases in anxiety, and the alleviation of their
experiences of depression. The healthier clients
more often reported increases in openness and
productivity. Fitzpatrick et al. (2006) suggested
that the incidents launched a positive emotion-
exploration spiral that promoted productive thera-
peutic work. For depressed clients, positive emotions
and the respite this offers them from their symptoms
may be the more salient entry point into the spiral;
those who have less severe symptoms may be more
ready to explore. Future studies should focus on the
influence of client affective disorders on the interac-
tion of positive emotion and exploration.
Horvath (2006) has suggested that the alliance is
probably both interpersonal/ collaborative or intra-
personal/internalized. An examination of the Mean-
ing of the Incident to the Client domain in the
current study shows that most of the categories are
interpersonal (e.g., ‘‘Therapist cares about me,
understands me, really listens to me and is skilled
in dealing with me’’); clients were focused on what
the therapists did for them. Most of the codes of
Fitzpatrick et al. (2006) highlight the intrapersonal
dimension (e.g., ‘‘I’m important*I’m the center,’’
‘‘I’m okay,’’ ‘‘I can do this myself too,’’ ‘‘Now I know
what to do here’’); these represent what clients did
for themselves. Although this difference might be
due to a different set of biases in the coding teams, it
is also possible that the differences are due to the
participants, either clients or therapists. We consider
both client and therapist explanations. We note,
however, that the design of the current study, in
which therapist experience and client problems were
different from those of Fitzpatrick et al. (2006),
precludes separating these effects in the comparison.
If the interpersonal�intrapersonal difference is due
to clients, client depression might be the reason.
Research indicates that those who are depressed see
positive events as due to external causes (Fresco,
Alloy, & Reilly-Harrington, 2006; Peterson, Bettes,
& Seligman, 1985). Consistent with this idea,
depressed participants attributed the meaning of
the event to what their therapists did. In Fitzpatrick
et al. (2006), the healthier group saw positive
meanings in their own ability to cope with the
situation. It is possible that depression may impact
alliance development by causing clients to focus
more on how the therapists contribute than on
valuing their own contribution.
We can also interpret the interpersonal�intraper-
sonal differences in the two studies in relation to
therapist experience. Alliance perceptions can be
influenced by the nature of the specific therapeutic
work (Bachelor & Salame, 2000). Expert therapists’
focus on treatment goals and relevant therapeutic
tasks (Summers & Barber, 2003) may draw clients’
attention to their caring, skill, understanding, or
listening. The uncertainty that is typical of novice
clinicians may serve to make clients more aware of
their own efforts. This idea is supported by the fact
that in the comparison study the description of the
critical incident ‘‘Therapist encouraged client to take
space’’ was unique to the incidents with the novice
therapists.
The current study and its comparison to Fitzpa-
trick et al. (2006) provide data to contribute to the
understanding of two important aspects of alliance.
First, client active exploration was a factor in
creating incidents that supported the development
of the alliance. Because exploration was not imme-
diately salient for participants, but could be brought
Client relationship incidents 663
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
into awareness, researchers may need to prompt
participants, and clinicians to prompt clients, to
articulate the nature of their collaboration. Second,
the interaction of the exploratory work with
the positive feelings*present in both studies*contributed to the critical incidents. Although de-
pression seemed to be associated with clients em-
phasizing the emotional over the exploratory aspect,
the interaction of exploration and positive feelings is
a potentially important mechanism for understand-
ing alliance development that warrants further
investigation.
Limitations
The comparisons and interpretations offered in this
discussion should be considered as a point of
departure for confirmatory research. Although the
sample size and procedures for participant selection
were appropriate for CQR analysis, the results
should be interpreted with caution. Because of the
small number of negative events reported, data
reflect positive critical relationship incidents. Parti-
cipants were selected based on a diagnosis of
depression. Different selection criteria such as per-
sonality disturbances, level of reflexivity, or quality of
interpersonal functioning might produce accounts of
incidents with different qualities. Interviews provide
only retrospective accounts that are subject to recall
biases and the limitations of awareness; unconscious
aspect of the relationship, including the transference,
was not available through the data collection and
analytic methods used. The data represent client
views of their working relationships; nonetheless,
direct comparisons to the alliance construct as it is
typically operationalized in alliance measures should
be made prudently. The time frame is a further
limitation. The interviews were conducted after the
third session of therapy and may be different from
alliance maintenance processes that are typical of
more developed relationships in later treatment. As
in any qualitative investigation, the coding represents
the unique perspectives of those researchers who
conducted the study. Although the consensual and
auditing processes were rigorous, a different group
could find different meanings in this data. Further to
this point, coding may have been influenced or
biased by preconceived understandings and expla-
natory constructs in ways that we cannot know.
Finally, in the comparison of the two studies, we
cannot extricate the aspects due to client diagnosis
from those resulting from therapist experience. The
data provide only a description of this group and are
subject to verification.
Acknowledgements
This research was supported by Social Sciences and
Humanities Research Council of Canada Grant 410-
01-0900. The authors gratefully acknowledge Sean
Kerry, Natasha McBrearty, Emma Naujokaitis,
Stephanie Hall, and Deidre Boyle for their assistance
in coding.
References
Ackerman, S. J., & Hilsenroth, M. J. (2003). A review of therapist
characteristics and techniques positively impacting the ther-
apeutic alliance. Clinical Psychology Review, 23, 1�33.
Acosta, F. X., Yamamoto, J., Evans, L. A., & Skilbeck, W. M.
(1983). Preparing low-income Hispanic, black, and white
patients for psychotherapy. Evaluation of a new orientation
program. Journal of Clinical Psychology, 39, 872�877.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC:
Author.
Bachelor, A. (1995). Client’s perception of the therapeutic
alliance: A qualitative analysis. Journal of Counseling Psychology,
42, 323�337.
Bachelor, A., & Salame, R. (2000). Participants’ perceptions of
dimensions of the therapeutic alliance over the course of
psychotherapy. Journal of Psychotherapy Practice and Research,
9, 39�53.
Battle, C. C., Imber, S. D., Hoehn-Saric, R., Strone, A. R., Nash,
E. H., & Frank, J. D. (1966). Target complaints as criteria of
improvement. American Journal of Psychotherapy, 20, 184�192.
Bedi, R. P. (2006). Concept mapping of the client’s perspective on
counseling alliance formation. Journal of Counseling Psychology,
53, 26�35.
Bedi, R. P., Davis, M. D., & Williams, M. (2005). Critical
incidents in the formation of therapeutic alliance from the
client’s perspective. Psychotherapy: Theory, Research, Practice,
Training, 42, 311�323.
Bordin, E. S. (1979). The generalizability of the psychoanalytic
concept of the working alliance. Psychotherapy Theory, Research,
and Practice, 16, 252�260.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences
(2nd ed). Hillsdale, NJ: Erlbaum.
Derogatis, L. R. (1977). The SCL-90 manual: Scoring, adminis-
tration and procedures for the SCL-90. Baltimore, MD: Clinical
Psychometrics Unit, Johns Hopkins University School of
Medicine.
Derogatis, L. R., & Cleary, P. A. (1977). Confirmation of the
dimensional structure of the SCL-90: A study in construct
validation. Journal of Clinical Psychology, 33, 981�990.
Dunkle, J. H., & Friedlander, M. L. (1996). Contribution of
therapist experience and personal characteristics to the working
alliance. Journal of Counseling Psychology, 34, 456�460.
Elliott, R. (1984). A discovery-oriented approach to significant
change events in psychotherapy: Interpersonal process recall
and comprehensive process analysis. In L. N. Rice & L.
Greenberg (Eds), Patterns of change (pp. 249�286). New York:
Guilford Press.
Fitzpatrick, M., Janzen, J., Chamodraka, M., & Park, J. (2006).
Critical incidents in the process of alliance development: A
positive emotion-exploration spiral. Psychotherapy Research, 16,
486�498.
Fresco, D. M., Alloy, L. B., & Reilly-Harrington, N. (2006).
Association of attributional style for negative and positive
events and the occurrence of life events with depression and
anxiety. Journal of Social and Clinical Psychology, 25, 1140�1159.
664 M. R. Fitzpatrick et al.
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
Gelso, C. J. (Ed.). (2006). Working alliance. Current status and
future directions [Special Issue]. Psychotherapy Theory, Re-
search, Practice, Training, 43(3).
Hatcher, R. L., & Barends, A. W. (2006). How a return to theory
could help alliance research. Psychotherapy: Theory, Research,
Practice, Training, 43, 292�299.
Hill, C. E., Knox, S., Thompson, B. J., Nutt-Williams, E., Hess,
S., & Ladany, N. (2005). Consensual qualitative research: An
update. Journal of Counseling Psychology, 52, 196�205.
Hill, C. E., Thompson, B. J., & Nutt-Williams, E. (1997). A guide
to conducting consensual qualitative research. The Counseling
Psychologist, 25, 517�572.
Holmes, S. (2008, June). Research on excellence in the clinical
practice of family therapy. Poster presented at the annual meeting
of the Society for Psychotherapy Research, Barcelona, Spain.
Horvath, A. O. (2006). The alliance in context: Accomplishments,
challenges and future directions. Psychotherapy: Theory, Re-
search, Practice, Training, 43, 258�263.
Horvath, A. O., & Bedi, R. (2002). The alliance. In J. C. Norcross
(Ed.), Psychotherapy relationships that work (pp. 37�69). New
York: Oxford University Press.
Horvath, A. O., & Greenberg, L. S. (1986). The development of
the Working Alliance Inventory. In L. S. Greenberg & W. M.
Pinsof (Eds), The psychotherapeutic process: A research handbook
(pp. 529�556). New York: Guilford Press.
Mallinckrodt, B., & Nelson, M. L. (1991). Counselor training
level and the formation of the psychotherapeutic working
alliance. Journal of Counseling Psychology, 38, 133�138.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the
therapeutic relationship with outcome and other variables: A
meta-analytic review. Journal of Consulting and Clinical Psychol-
ogy, 68, 438�450.
Mohr, J. J., & Woodhouse, S. S. (2001). Looking inside the
therapeutic alliance: Assessing clients’ visions of helpful and
harmful psychotherapy. Psychotherapy Bulletin, 36, 15�16.
Peterson, C., Bettes, B. A., & Seligman, M. E. P. (1985).
Depressive symptoms and unprompted causal attributions:
Content analysis. Behavioral Research & Theory, 23, 379�382.
Reis, B. F., & Brown, L. G. (2006). Preventing therapy dropout in
the real world: The clinical utility of videotape preparation and
client estimate of treatment duration. Professional Psychology:
Research and Practice, 37, 311�316.
Samstag, L. (2006). The working alliance in psychotherapy: An
overview of the invited papers in the special section. Psychother-
apy: Theory, Research, Practice, Training, 43, 300�307.
Saatsi, S., Hardy, G.E., & Cahill, J. (2007). Predictors of outcome
and completion status in cognitive therapy for depression.
Psychotherapy Research, 17, 185�195.
Sexton, H. C., Hembre, K., & Kvarme, G. (1996). The
interaction of the alliance and therapy microprocess: A sequen-
tial analysis. Journal of Consulting and Clinical Psychology, 64,
471�480.
Summers, R. F., & Barber, J. P. (2003). Therapeutic alliance as a
measurable psychotherapy skill. Academic Psychiatry, 27,
160�165.
Timulak, L. (2007). Identifying core categories of client-identified
impact of helpful events in psychotherapy: A qualitative meta-
analysis. Psychotherapy Research, 17, 305�314.
Timulak, L. (in press). Meta-analysis of qualitative studies: A tool
for reviewing qualitative research findings in psychotherapy.
Psychotherapy Research.
Timulak, L., & Elliott, R. (2003). Empowerment events in
process-experiential psychotherapy of depression: An explora-
tory qualitative analysis. Psychotherapy Research, 13, 443�460.
Tryon, G. S., Blackwell, S. C., & Hamel, E. F. (2007). A meta-
analytic examination of client therapist perspectives of the
working alliance. Psychotherapy Research, 17, 629�642.
Zuroff, D. C.., & Blatt, S. J. (2006). The therapeutic relationship
in the brief treatment of depression: Contributions to clinical
improvement and enhanced adaptive capacities. Journal of
Consulting and Clinical Psychology, 74, 130�140.
Zwick, R., & Attkisson, C. C. (1985). Effectiveness of a client
pretherapy orientation videotape. Journal of Counseling Psychol-
ogy, 32, 514�524.
Client relationship incidents 665
Dow
nloa
ded
by [
The
Uni
vers
ity o
f M
anch
este
r L
ibra
ry]
at 1
3:47
15
Oct
ober
201
4
