Levitt, H., Butler, M., & Hill, T. (2006). What clients find helpful in psychotherapy: Developing principles for facilitating moment-to-moment change. Journal of Counseling Psychology, 53 (3), 314-324.
Editor’s Note: The field of mentoring can learn a lot from research on other helping professions. With this in mind, Laura surveyed the literature on psychotherapy relationships.
What clients find helpful in psychotherapy: Implications mentoring relationships
Summarized by Clinical Psychology Ph.D. Student Laura Yovine.
A major critique of psychotherapy outcome studies is the lack of information indicating how a therapist should behave on a moment-to-moment basis during the therapy session. Thus, Levitt and colleagues conducted a qualitative study to pinpoint clients find helpful in the interpersonal process of change. The findings may have important implications for mentoring.
Clients (N = 26) who had previously (2 to 12 months prior) completed individual psychotherapy sessions were interviewedand asked to reflect on their therapy experience. Participants had a wide range of presenting problems and were treated by therapists of various therapeutic orientations. The semi-structured interviews lasted approximately 1.5 hours and focused on the client describing what was important or significant (positive or negative) to them (1) about their psychotherapy in general, (2) in specific psychotherapy moments, and (3) in their therapeutic relationship. In addition, clients completed questionnaires on the strength of the alliance with their therapist and an outcome measure assessing the amount of change due to therapy. Transcripts of the interviews were analyzed for patterns using grounded theory methods; first, significant moments were identified and then clusters of behavior and/or attitudes were formed.
Patterns of client responses were categorized as follows:
1) Commitment to Therapy:
- Clients varied in their expectations for therapy; those who reported negative initial perceptions noted that it helped develop commitment to therapy when the therapist directly discussed the client’s “shame or fear of examining threatening topics.”
2) The Therapy Environment as a Reflection of Therapists’ Care
- the therapy room was described as a projection of the therapist and a reflection of his/her care for clients
- clients attributed feeling safe, comfortable, and relaxed due to the physical condition of the therapy room
3) Out-of-Session Processing:
- “The ending and beginning of sessions were particularly difficult for clients”
- Some clients noted how it was beneficial to allow time at the end of a session to become less emotional; other clients reported how therapy gave them “strength to maintain a reflexive stance” between sessions
4) The Therapeutic Relationship:
- 21 of the 26 clients indicated that their relationship with their therapist was a central part of therapy and described them as understanding, impartial, and reliable
- “it appeared that the therapist acted as a surrogate for others’ approval until the client had developed a strong enough sense of self-approval”
- “clients’ trust deepened after revealing vulnerable aspects of themselves and perceiving the therapist as responding in a caring way.”.
- when a therapist would actively break rules in the structure of the therapy session it had the potential to demonstrate the therapist’s investment and thus strengthen the relationship, however, if the transgression makes the client feel uncomfortable it could weaken the alliance
5) Therapist Characteristics:
- Clients described a therapist personality as problematic if he/she was perceived as either too distant (i.e. defensive, unattuned, insensitive) or if he/she was over-involved (i.e. jealous, controlling, or pitying).
- Challenging by the therapist was generally ill-received, unless it was used to confront clients who were being manipulative or avoidant.
- Emotional expression on behalf of the therapist was seen as humanizing as long as it reflected concern about the client.
6) Therapeutic Intervention:
- Therapists used a variety of intervention techniques but in general clients liked engaging in structured therapeutic tasks
- Therapists were able to promote self-discovery by offering different perspectives, questioning, and pointing out patterns of behavior
The core finding of all the clusters is that “clients are needing just enough structure to facilitate reflexivity while needing to feel special enough to risk revealing and to be known.”
Overall, this study contributes strong qualitative research to the examination of processes and outcomes in psychotherapy. Specifically, the findings of this study aim to sensitize therapists to the needs, expectations, and behaviors of clients while informing their therapeutic decision-making on a moment-to-moment basis.
Implications for Mentoring:
Given the quasi-therapeutic nature of the mentor-mentee relationships, many of the findings of this study hold great implications for mentoring practices. For example, discussing a mentees expectations of the relationship and working through any initial negativity and/or resistance may contribute to commitment. Therapy clients also discussed the difficultly in transitioning from therapy back to “real life,” this is an important consideration for mentors to take into account when discussing emotionally-heavy issues with their mentees; it may been beneficial to allot time at the end of mentoring session for a more “fun” activity.
As aforementioned, the majority of clients indicated the relationship with their therapist was a central part of therapy, this aligns with mentoring studies that highlight the importance of relationship quality in achieving positive youth outcomes. Furthermore, the idea of crossing boundaries may have a similar affect for mentees as it does with clients in making mentees feel that their mentor is more invested in the relationship. However, over-involvement, excessive self-disclosure, pitying, or other types of transgressions may make the mentee feel discomfort and harm the relationship. Lastly, mentors could use the therapeutic tactics to help facilitate self-discovery in their mentees by offering novel perspectives, questioning, and pointing out behavior patterns that may not be obvious to the mentee.
It is important to note, additional studies are necessary to fully translate psychotherapy findings into the mentoring arena, nevertheless psychotherapy research offers an excellent source of ideas to consider implementing into the training of future mentors.