For decades, clinicians have been interested in understanding the within-session interactions and specific factors that influence dynamics in counseling and psychotherapy. This interest in what happens in therapy, namely, the therapeutic process, spans disciplines of psychology, psychiatry, and social work. However, the large number of psychotherapeutic approaches, the assumptions underlying what therapeutic process entails, and the complexity inherent in understanding how therapy works has made studying process a daunting task. The bulk of research on the counseling therapy process occurred between the 1970s and 1990s. The earlier research focused on therapist variables and response modes by isolating single overt behaviors and assessing significant moments or events within the context of particular theoretical models. By the 1990s, the recognition of the therapeutic process as complex, interdependent, and based in overt and covert behaviors led researchers to examine process within the context of theoretical integration and technical eclecticism. Process is currently seen to be embedded in common therapist-client factors.
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Counseling Therapy Process Definition
In order to understand what constitutes “process,” it is important to distinguish it from other related aspects of therapy, namely, input variables, extratherapy variables, and outcome variables. Input variables refer to therapist demographics, personality, expectations, and theoretical orientations, whereas extratherapy variables refer to personal or world events that clients experience outside the therapeutic interaction. Outcome refers to changes that occur as a result of the therapeutic process (e.g., client satisfaction). While outcome and process may overlap as in the case of client insight or the working alliance, process is concerned with the intra- and interpersonal actions and interactions embedded in patterns of relationships. Specifically, Clara E. Hill and Maureen M. Corbett defined process as the overt and covert thoughts, behaviors, and feelings within psychotherapy sessions that pertain to the therapist and the client and the interaction between the two.
Initial Approaches to Understanding Counseling Therapy Process
Early attempts to understand process were focused on what therapists do in counseling therapy. As early as the 1920s, Sigmund Freud, Earl F. Zinn, and Percival M. Symonds recorded analytic and nonanalytic interviews to enable content analysis of sessions. In 1938, Frank Robinson started the first process research program in Counseling Psychology at Ohio State University. Session recordings helped identify both overt and covert therapist and client behaviors in therapy (e.g., self-disclosure, self-talk), with focus on therapist patterns across clients (e.g., interpretation, empathy). Carl Rogers’s “nondirective therapy” continued to emphasize the therapist’s role, identifying specific therapist skills. Although Rogers was opposed to focusing on therapist behaviors, in 1957, Rogers’s necessary and sufficient conditions (i.e., empathy, genuineness, and positive regard) became the primary indicators of therapeutic change. The focus on therapists’ role in the therapeutic process continued with Robert R. Carkhuff’s model that emphasized therapists’ skills as important in creating client change. However, he suggested that it was primarily the therapist that was doing something to create change. In 1984, Laura N. Rice and Leslie S. Greenberg suggested a need to examine clients’ roles in creating change. At this time, the focus shifted to clients’ behaviors and therapists’ behaviors were seen as contextual sources of influence (e.g., expertness, attractiveness).
There were several assumptions underlying the initial conceptualization of counseling therapy process as therapist guided. The first assumption was that therapeutic process was theory driven, meaning that what happened in the therapy session was directly related to the therapist’s theoretical orientation. However, in 1936, Saul Rosenzweig noted the uniform efficacy of different psychotherapies and proposed that there were some common factors across therapeutic approaches that were central to the therapy process. Numerous researchers strongly endorsed the presence of common factors or ingredients that influenced positive outcomes. However, while studies advocated for common factors, a second assumption underlying process research was the notion of homogeneity of process, or the idea that process was similar across clients (e.g., specific therapist behaviors or interventions would result in particular client responses regardless of when they occur in therapy). Arguments against this assumption note that process is contextually bound and varies over time, across therapists and clients, and in different situations. Similarly, other research points out the inappropriateness of drawing conclusions on the direction of influence on therapy process by examining the amount or frequency of a particular behavior (e.g., that a particular client behavior would follow a particular therapist intervention). The general consensus was to shift from isolating variables (e.g., examining the mere occurrence of behaviors) to understanding the pattern of contextualized variables or factors that influence therapeutic process. Furthermore, in 1986, David E. Orlinsky and Kenneth E. Howard highlighted that the therapeutic process entails a “dialogue” or “exchange” between clients and therapists with behaviors being influenced by the interpersonal relationship. This resulted in the therapeutic process being seen as an interpersonal, mutually constructed social change process with some common factors influencing the therapy process. As a consequence, several models of counseling therapy process evolved.
Models of Counseling Therapy Process
The relevance of overt and covert therapist and client behaviors has influenced the development of process models proposed by authors such as Hill and Kevin O’Grady, Jack Martin, Orlinsky and Howard, and William Stiles. In particular, the belief that events or behaviors in therapy occur at different levels of awareness for both therapist and client, and that their individual construals of the event can define how the interactions proceed has significantly influenced what factors are thought to impact therapy process. This cyclical nature of the psychotherapy process suggests that a therapist conceptualizes the client’s issue based in a theoretical formulation, and decides on an intervention that may be based in verbal or nonverbal response modes. The client reacts to the therapist’s intervention based on his or her construal of the therapist’s intentions. The therapist then reacts to the client’s response and formulates the next intervention. This continuous cycle of therapist and client interaction is embedded in the relationship that evolves within this context. In keeping with this continuous interplay between therapist and client intentions, interventions, perceptions, and behaviors, several authors, such as Stiles, Orlinsky and Howard, Hill, and Bruce Wampold, have highlighted the notion of integrating specific common factors into the therapy process. Contemporary views of the counseling therapy process suggest that while there may be specific therapist techniques or client tasks that differ across theories, the therapy process is pantheoretical, with some common interconnected factors across therapies that include specific contributions from therapists, specific contributions from clients, and some mutual relationship factors.
Therapist Contribution to Counseling Process
Upon entering the therapy room, therapists bring not only their professional training but also their personalities and interpersonal styles, based in their upbringing and culture. The idea that these unique therapist input variables would influence what happens in therapy is both intuitive and empirically supported. In fact, the therapist factors that may cause therapy to progress, stall, change course, or end are complex and interdependent. Research has focused specifically on two classes of such processes—those that can be observed by a person outside the therapy relationship (overt), and those that reflect internal experiences of the therapist (covert).
Therapist Overt Processes
Therapeutic techniques include the particular methods or strategies employed by therapists within a session to facilitate beneficial change in a client. Techniques were originally conceptualized as belonging to specific theoretical camps (e.g., two-chair technique in Gestalt therapy), and allegiance to a particular theoretical orientation does influence therapists’ choice of intervention. Endorsement of eclectic approaches to therapy, however, has made it quite typical for therapists to “borrow” techniques from various theoretical traditions to cater to treatment contexts and clients’ needs. Furthermore, intensive studies of therapy process actually suggest significant commonality across techniques that are described with different terms.
Hill posited that therapists use certain techniques according to the evolution of the therapy process. Supportive and informational techniques predominate during initial contact with the client, while exploratory techniques are preferred as the relationship deepens. Therapists may turn to theory-specific techniques during the “core work” of therapy, and to termination techniques as therapy comes to a close.
Verbal response modes represent a special subgroup of techniques that have been investigated in relation to in-session and distal therapy process. Verbal response modes refer to the grammatical structure of what therapists say, independent from their content or the context in which they are said. Verbal responses include open or closed questions, direct guidance, confrontation (pointing out incongruence), approval, paraphrasing, interpretations, and therapist self-disclosure. Theoretical orientation has been noted as influencing therapists’ choice of response mode (e.g., psychodynamic therapists use interpretation more often than behavioral therapists).
While certain response modes have been identified as particularly helpful in producing immediate outcomes, researchers have suggested that the combination of responses with other process variables may produce cumulative impacts on outcome. Specifically, the skill and manner in which interventions are delivered may critically influence how they are received by the client and subsequently impact therapy process.
Therapists’ nonverbal behavior also influences what occurs in therapy. Nonverbal behavior conveys emotion and attitudes towards the self and others, adds other dimensions of meaning onto what is stated verbally, and reflects sociocultural rules about communication. Paralanguage (e.g., speech intensity and volume), facial expressions, eye contact, posture, proxemics (use of physical space in the therapy room), and touch are all relevant means of communicating in therapy.
Therapist Covert Processes
While overt processes provide some information about how therapists proceed in therapy, understanding what is going on internally for the therapist (e.g., how therapists’ internal thoughts and feelings influence his or her verbal responses in session) may be equally or even more relevant to therapy process. Attention to covert dynamics is an important step in the evolution of therapy process research, and relevant areas of study include therapist intentions, self-talk or internal dialogue, and countertransference.
Therapist Intentions. Examining a therapist’s reasons for using particular interventions is important to our understanding of therapy process. Some common therapist intentions acknowledge client needs. These include setting limits; assessing; providing support; educating/giving information; exploring cognitions, behaviors, and feelings; and restructuring. Other intentions may reflect the therapists’ needs, such as defending oneself, alleviating anxiety, or feeling superior to the client. Importantly, Hill and her colleagues suggested that therapists’ intentions may be better descriptors of interventions than what therapists actually say. Finally, while therapists’ ability to articulate their intentions has been linked with outcome, therapists may not always be aware of their intentions, or they may have specific wishes that the client know, or not know, their intentions. All these factors can influence how intentions shape counseling therapy process.
Self-Talk. Therapist self-talk refers to therapists’ internal dialogue, or things they say to themselves during session. Self-talk is a common occurrence in therapy that can relate to both positive feelings (e.g., empathy, caring) and negative feelings (e.g., frustration, distraction), and may interfere with counselors’ ability to provide effective counseling. Counselors who struggle with their reactions may display negative or incongruent behavior, avoid or suppress specific affect or issues, and become overfocused on an issue or the client. While the self-talk literature is still evolving, findings to date suggest it is a complex process that can have far-reaching implications for therapy process, and would benefit from continued examination.
Countertransference. Rooted in psychoanalytic literature, countertransference was traditionally referred to as the therapist’s unconscious, countertherapeutic reactions to the client’s transference. Other definitions have included all of the therapists’ reactions to the client, including reactions to the client that reflect the therapist’s unresolved conflicts. While theorists continue to disagree on an exact definition, most research focuses on the latter definition and considers countertransference to be pantheoretical and a potentially hindering factor to therapy process if left “untreated.” Research has identified some factors associated with counter-transference reactions, as well as how therapists react to countertransference (e.g., feeling bored or angry).
Client Contribution to Counseling Process
In 1992, Michael Lambert noted that 40% of variance in outcome (e.g., client improvement) was related to client variables and extratherapeutic factors (factors outside the therapeutic relationship). The focus on clients assumes clients are active agents who more often than not intentionally seek out therapy, engage with the therapist, and become involved in the therapeutic process. While the therapist serves as a guide, it is the client who ultimately decides the extent to which change will be made. Several approaches have been taken to understand client behaviors. Research has examined behaviors that are either present or absent in the therapeutic session, topics that clients discuss in therapy, how clients experience therapy, how clients progress, how they assimilate different experiences, and clients’ cognitive complexity. An overarching construct that subsumes these behaviors is client involvement in therapy. As with therapist contributions, the focus on client contributions to therapy process identifies both overt and covert client behaviors as active ingredients in counseling therapy process.
Client Overt Processes
Client overt processes can manifest in terms of client involvement and resistance. Client involvement refers to the extent to which clients are open to the therapeutic process, engaged and motivated within the session, and are actively immersed in the process. Involvement refers to clients’ readiness for change through initiation of topics, exploration of presenting problems, participation in change-oriented activities, and expressed comfort in informing therapists of their reactions and problems in therapy. Involvement can also be influenced by client expectations of counseling therapy.
Conversely, depending on theoretical orientations, client resistance has been identified in different terms. For example, behaviorally, resistance has been identified in clients’ complaining, self-blaming, disagreeing with therapist, pushing their own agenda, sidetracking, not responding, and defending others. Psychodynamically, it has been seen in the form of recollection of material and deflection of pain or affect.
Client Covert Processes
Client covert processes, on the other hand, refer to reactions and feelings that are not readily observable. Clients contribute to therapy process through the reactions they have to therapist interventions. For example, client reactions can be positive (e.g., feeling understood, viewing interventions as helpful) or negative (e.g., feeling stuck or misunderstood). Subsumed under the negative reactions are hidden reactions or nondisclosures. These can manifest in the form of secrets about life experiences that clients do not share with their therapist. Research suggests that clients hide their negative reactions from their therapists due to their fear of retaliation, or deference to therapists’ authority, or feeling unsafe in therapy. Clients also refrain from sharing their reactions because they may be dissatisfied with therapy, feel vulnerable, or feel that their therapists may not understand them or their emotions. Embarrassment or shame about specific issues may also prevent clients from sharing their thoughts. While therapists may not be able to assess nondisclosures, literature suggests that being tuned into clients’ nonverbals during a session might shed some light in assessing nondisclosures.
Finally, one important contribution from psychoanalytic theory that influences the therapeutic process from the clients’ end is transference. Freud defined transference as a client’s mental representation of early interpersonal relationships that are often distortedly imposed onto the therapist. These representations often are idiosyncratic, may be positive, negative, or mixed, and can manifest differently for various clients and therapists. However, it is also believed that transference may reflect the interpersonal interaction between the therapist and the client.
Interactions between Therapists and Clients
To reiterate an old, but germane point, what happens in therapy is inherently interpersonal, and the ways clients and therapists relate to each other impact what happens in counseling therapy. The interactional dynamics between the therapist and client have been considered in light of relational control theory. This perspective draws attention not only to what is said, but also how therapists and clients determine the nature and timing of their communication in therapy. The interpersonal transactions between the therapist and client are developed, defined, and mutually constructed within the social system of the dyad. These transactions have been discussed in the literature as relationship control, relationship defining, or turn taking. The process of negotiating fit between clients’ and therapists’ transactional patterns can have important influences for therapy process. Thus, understanding the therapy process requires attention to the patterns of communication between the therapist and client, including how rules about dyad-specific communication are developed, how speaking turns are defined and occur, who initiates shifts in topics, and how clients may internalize the therapeutic relationship.
Increasing evidence suggests that the strength of the therapeutic alliance, often used interchangeably with the terms working alliance and helping alliance, is the strongest and most reliable predictor of positive therapeutic change. Originating in psychoanalytic theory, Edward S. Bordin’s quintessential conception of the working alliance emphasized mutually agreed-upon goals and tasks of counseling therapy, and the reciprocal bond or emotional attachment between therapist and client. Research on the therapeutic bond posited three interpersonal subprocesses related to role and attachment functions in the therapy relationship: mutual collaboration on and pursuit of therapeutic objectives, interest and attention to one another, and reciprocal respect and emotional affirmation. The alliance currently reflects a pantheoretical concept that clinicians generally agree to be relevant within all therapeutic contexts. Attention has been paid to both therapist and client contributions to the therapeutic alliance.
Therapist Contributions to the Alliance
Several therapist factors have been found to be related to stronger therapeutic alliances, including personal characteristics, comfort with close interpersonal relationships, low hostility, and sensitivity to cultural differences. Additionally, although not related to counseling competence, the therapist’s level of professional experience may suggest a greater likelihood of successfully engaging clients in the mutual construction of tasks and goals, which is strongly associated with effective outcomes. Finally, specific interventions, such as focusing on the here and now, focusing on nonverbal communication, defense mechanisms, interpersonal dynamics in the therapy relationship, and making accurate interpretations, are also associated with a stronger therapeutic alliance.
Client Contribution to the Alliance
Clients’ interpersonal strengths, such as friendliness, submissiveness, and social competence, and the quality of their past and current interpersonal relationships, have been found to be predictive of a stronger therapeutic alliance. Conversely, avoidant attachment styles and the extent to which clients cannot trust relationships early on are predictive of a weaker alliance. However, not all clients view the alliance in a similar manner. For instance, clients may perceive the alliance as collaborative, insight oriented, or nurturant. While both interpersonal characteristics and early attachment styles may influence the development of an alliance, further research is needed in this area.
Problems in the Alliance
As a central feature of most counseling therapies, the therapeutic alliance is prone to a number of problems as therapists and clients proceed in therapy, all of which contribute to fluctuations in the therapy process. Jeremy D. Safran and his colleagues, Peter Crocker, Shelly McMain, and Paul Murray, discussed “ruptures” in psychotherapy, referring to difficulties that develop due to defiant behavior. Bordin posited that the “rupture and repair” process of building and maintaining the alliance represented the real work of therapy, although other perspectives consider a solid alliance to be necessary in order for specific interventions to effect change. From the client’s end, ruptures may manifest through overtly expressing negativity toward the therapist (such as challenging the therapist’s competence), indirectly communicating hostility (i.e., showing up late to appointments), disagreeing over tasks or goals, avoidance behaviors, or nonresponsiveness to interventions. Mistakes or misunderstandings on the therapist’s part may also result in impasses. Disagreements with tasks and goals of counseling therapy, triangulations in relationships with significant others, transference, therapist personal issues, level of client pathology, and/or therapist interventions (i.e., being too direct) may harm the alliance. Understanding the types of impasses, and client-therapist styles (e.g., hostile or supportive) can help improve our understanding of the therapeutic process as problems evolve in the alliance.
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