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This is to certify that the

thesis entitled

An Exploratory Study of "Critical
Sessions" in Individual Adult
Psychotherapy

presented by
Neil Edward Rand

has been accepted towards fulfillment
of the requirements for

Doctoral degree in Psychology

 

 

4Wfl2~ek

// / “ajor professor

Griffith Freed, Ph.D.

0-7 639

AN EXPLORATORY STUDY OF "CRITICAL SESSIONS"
IN INDIVIDUAL ADULT PSYCHOTHERAPY

BY
Neil E. Rand

A DISSERTATION'

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

‘Department of Psychology

1978

ABSTRACT

AN EXPLORATORY STUDY OF "CRITICAL SESSIONS"
IN INDIVIDUAL ADULT PSYCHOTHERAPY

BY
Neil E. Rand

This research sought to study the nature of "critical
sessions" in individual adult psychotherapy. Theoretically,
a "critical session" was conceptualized as a session in the
process of therapy in which the therapist confronted or
interpreted some key set of feelings or behaviors to which
the client is receptive, and which results in the client
having felt some significant emotional impact, having
achieved a sense of mutual closeness with the.therapist,
having had some major cognitive reorganization, having
achieved some important insight in a way that is useful,
and having shifted some of his or her distorted perceptions
of the therapist more toward reality.

The concept of a "critical session" had to be opera-
tionally defined. This was accomplished for this study
by a surVey of experienced psychotherapists. Data from a
preliminary set of interviews with experienced therapists
was used to construct the Psychotherapist Survey Question-
naire (PSQ). The PSQ was sent to 62 experienced therapists
and researchers to collect data on their views on whether

"critical sessions" exist, and, if they believed so, what

variables might be present in such sessions. Forty-six
respondents agreed with the concept, while six did not,
and ten did not respond. The 46 positive respondents, who
had a mean experience level of 14.4 years, identified
three variables (PSQ items VI, IX, and X) which they con-
sidered "extremely important" to a "critical session". A
t-test performed on the PSQ data showed the responses for
these three items to be significantly different from the
total group of PSQ responses (p<.0005).

These three PSQ items were converted into seven items
on the "Critical Session" Questionnaire (CSQ), an instru-
ment developed for this study with the aim of identifying
"critical sessions". Two additional items concerning the
importance of the session and the client's goals for therapy
were also included in the C80. The operational definition
for a "critical session" for this study was the highest
median for a client's ratings for a session on these nine
CSQ items, with at least seven of these items needing to
be rated at equal to or greater than + 2.

It was hypothesized that (l) a change in the client's
report of his or her affect from the session immediately
preceding a "critical session” to the session immediately
following a "critical session" as measured by the Multiple
Affect Adjective Check List would occur (p:.05), and (2)
that a change in the therapist's report of the client's

experienced affect over these same sessions measured by

the same instrument would occur (p:.05).

Ten adult clients in individual therapy and their
therapists were administered the C80, the Multiple Affect
Adjective Check List (MAACL), and the Therapy Session
Report (TSR) after each of ten consecutive sessions.
Therapists chose both the clients and the starting points
in the therapy process for this research. Five dyads
started participating in this study before the twentieth
session and five began at some point after the twentieth
session.

Eight of the ten dyads were found to have had an
operationally defined "critical session." A t-test per-
formed on the C80 results demonstrated that these eight
"critical sessions" were significantly different in their
CSQ client ratings than the total group of sessions
studied (p<.0005). A three-way analysis of variance was
performed-on the MAACL scores for the eight "critical
sessions," the sessions immediately preceding and follow-
ing them, and on three randomly selected consecutive
sessions from these same dyads which served as controls.
The results of the analysis of variance (1) failed to
support either of the hypotheses, and (2) failed to demon-
strate that the identified "critical sessions" were
different than other sessions in their client MAACL

scores. Three TSR items pertaining to variables in the

theoretical definition of a "critical session" were then
subjected to a similar three-way analysis of variance.
This statistical analysis also failed to differentiate
"critical sessions" from other sessions. Finally, items
involving which client affect was felt most, what was
talked about most, and what was most beneficial to the
client during the eight "critical sessions" were examined
in a non-statistical manner. Two trends were discovered:
(1) Past or present relationships with members of the
client's immediate family was the most frequently reported
content matter (43%), and (2) Attaining greater under-
standing or insight was most frequently reported to be
what the client got most out of the session (43%).
Although the hypotheses were not supported, "criti-
cal sessions" were identified in eight therapy dyads and
some trends concerning the nature of "critical sessions"
were uncovered. Some of the methodology utilized in
this study may have contributed to the lack of significant
results, e.g., the small number of subjects, the types of
instruments used and their length, and the examination of
only ten sessions rather than the entire course of a
therapy. Enough information was collected, however, to
suggest the value of further research in the area of

"critical sessions" using more refined methodology.

TABLE OF CONTENTS

Page
Introduction and Review of the Literature . . . . 1
Introduction . . . . . . . . . . . . . . . . 1

Review of the Research on “Critical Sessions"
in Psychotherapy . . . . . . . . . . . . 3

The Value of This Study . . . . . . . . . . 10

Review of the Literature on the Nature of
a "Critical Session" . . . . . . . . . . 14

Theoretical Definition of a "Critical
Session" . . . . . . . . . . . . . . . . 25

Method . . . . . . . . . . . . . . . . . . . . . 26

Operational Definition of a "Critical
Session" . . . . . . . . . . . . . . . . 26

' Hypotheses . . . . . . . . . . . . . . . . . 28
Subjects and Settings . . . . . . . . . . . 31
Instruments . . . . . . . . . . . . . . . . 32
Procedure . . . . . . . . . . . . . . . . . 44

Selection of an Operationally Defined
"Critical Session" for Analysis . . . . . 45

Statistical Procedures . . . . . . . . . . . 46
Results . . . . . . . . . . . . . . . . . . . . . 48
Discussion . . . . . . . . . . . . . . . . . . . 72

Methodological Considerations . . . . . . . 80

Implications for Future Research . . . . . . 86

Summary and Conclusions . . . . . . . . . . . . . 94

ii

TABLE OF CONTENTS (continued)

Appendices
A. The Psychotherapist Survey Questionnaire
B. The Client Background Questionnaire
C. The Therapist Background Questionnaire (Client Form)
D. The "Critical Session" Questionnaire

E. The "Critical Session" Questionnaire (Thera-
pist Form)

F. The Multiple Affect Adjective Check List
(Client Form)

G. The Multiple Affect Adjective Check List
(Therapist Form)

H. The Therapy Session Report (Client Form)
.I. The Therapy Session Report (Therapist Form)

J. Instructions to Therapists

K. Consent for Participating in Research Form

L. Results Obtained From the Therapist and Client
Background Questionnaires

Bibliography

iii

LIST OF TABLES

Table Page
1. Results of "Critical Session“ Questionnaire . 55

2. Starting Sessions and Occurrence of "Critical
Sessions" for the Therapy Dyads . . . . . 58

3. Analysis of Variance for MAACL Anxiety (A)
scale C O O O O O O O O O O O O O O O O O 60

4. Analysis of Variance for MAACL Depression (D)
scale 0 I O O I O O O C O O O O O O O O O 61

5. Analysis of Variance for MAACL Hostility (H)
Scale . . . . . . . . . . . . . . . . . . 62

6. The One Feeling Felt Most by the Client
During His or Her "Critical Session" . . . 65

7. The One Subject Talked About Most by the
Client During His or Her "Critical
Session" . . . . . . . . . . . . . . . . . 66

8. What the Client Got Most Out of His or Her
"Critical Session" . . . . . . . . . . . . 68

9. Clients' Responses to CSQ Item 13: "What
was most helpful to you in today's
session?" for His or Her "Critical
Session" . . . . . . . . . . . . . . . . . 70

iv

INTRODUCTION AND REVIEW OF THE LITERATURE

INTRODUCTION

 

Despite the amount of research done in the field of
psychotherapy, many basic questions pertaining to theory
and practice have yet to be answered. One essential
but little researched question is the possibility
of differentiating sessions that are deemed to be important
to the progress of a client's psychotherapy from those
sessions which are judged as of less or little importance.

It is a problem of both conceptual and pragmatic
concern. Often a therapist who has just finished meeting
with a client exclaims, "That was a really good session,"
or "That was an important session." When questioned
about this statement and about the "important" session,

a therapist may explain the meaning of his exclamation

in terms of his own particular theoretical constructs;

or he may verbalize it more concretely by describing the
behaviors and feelings that ensued during that session;

or he might combine these two facets by depicting the
processes that occurred; or he may relate his own internal
feeling states; or he may simply be unable to offer any
other explanation than some sort of intuition. Even among
therapists who can cite reasons for their statement, few

explanations are similar in content or theory espoused.

l

One also occasflionally hears a therapist refer to a
particular session with a particular client as "critical"
or as "a turning point in therapy." These phrases are no
better defined. Exploring this remark often leads to the
same multiplicity of responses as were engendered by the
question of what constitutes an "important" session. The
wide variety of answers and the amount of uncertainty con-
cerning such common occurrences in the practice of psycho-
therapy, seems puzzling. Certainly the frequency of such
responses indicates this importance in the process of
therapy. Even more puzzling is the fact that the frequency
of such sessions has not warranted particular interest on
the part of researchers to investigate their attributes.

The difference between what constitutes a therapy
session evaluated informally (or quantitatively) as "good"
or "important" from a session judged "bad," "poor," "neu-
tral," "unimportant," or "of lesser importance" would seem
to promise to generate a fair amount of data concerning
both the nature and the process of psychotherapy. Taking
the extreme example on this continuum, namely sessions
rated as "critical" or "turning point,” and examining in a
comprehensive manner what occurs at these times could con-
ceivably be an even greater source of data for the explora-
tion of the essential components of psychotherapy.

Consequently, this study hopes to formulate a system-

atic, operational definition of a "critical session."

This study also seeks to examine some of the constituent
factors involved in the process of these sessions. Out-
come will not be evaluated in this research. This invest-
igation focuses primarily on finding therapist-client
interactions and therapeutic processes common to "critical
sessions" which serve to differentiate these sessions from
all other sessions. This study hopes to examine some of
the variables in the process of "critical" therapy
sessions and enable the researcher to form some tentative

hypotheses concerning the nature of these sessions.

Review of The Research on "Critical Sessions" in Psycho-
therapy

Of all the research studies performed in the field
of psychotherapy in recent years there has not been a
single published empirical study that examines "critical
sessions" or critical incidents in the process of psycho-
therapy. Three studies explore the concept of the "good
hour" in psychotherapy. Since the notion of the "good
hour" as perceived by these researchers is similar to the
idea of an important session, these three studies will
be examined here.

Mintz, Auerbach, Luborsky, and Johnson (1973) studied
four patients for twelve consecutive sessions each. The
patients' diagnostic description was supplied. Each
patient was seen by a different, experienced, psycho-

analytically-oriented psychiatrist. The authors factor

analyzed Orlinsky and Howard's Therapy Session Report
into six factors, which they demonstrated to be similar
to those obtained by Orlinsky and Howard (1967). They
then related these factors to the judgments of client,
therapist, and observer, and to the "goodness" of the
session. The first set of results showed that all
judgments from all three groups (clients, therapists,
and observers) correlated about equally with one another,
with the range being from r=.40 to r=.49. For the
"goodness" of the session the authors correlated the
six factors with only a single item on the Therapy
Session Report which measures "goodness". This practice
of using a single item for so complex a variable greatly
reduces the validity of their obtained results and
limits the conclusions they may draw. Their findings
were that "goodness" of the session correlated highly
with the Helpful Involved Therapist factor (r=.66,
p<.01), and at lower but still significant levels with
Active Experiencing Patient (r=.40, p<.Ol) and Affection
and Sex (r=.27, p<.Ol).
They conclude that

"evaluation of the goodness of the

therapy hour is intimately and strongly

tied to the judge's perception of the

therapist's quality of relationship;

further, that the judge's perception

of the depth and appropriateness of the

patient's involvement in the therapeutic

process also plays a role in evaluating

the session's goodness, although a dis-
tinctly lesser role" (p. 88).

Although the overall agreement between the groups and
between the Observers within their group was good, the
agreement between ratings obtained on the Helpful
Involved Therapist factor was low for both of these
comparisons. For these methodological reasons, the
conclusions drawn by Mintz, et a1. seem contradictory,
confusing, and unreliable.

Auerbach and Luborsky (1968) set out to determine
how change comes about in the process of psychotherapy.
This study used three judges, whose inter-judge relia-
bility was not previously established, to rate tape
recorded therapy sessions. After a training period the
judges interpreted the types of therapist or patient
variables being expressed in the sessions from listening
to the content. In addition to these, the author listed
therapist and patient variables compiled from a number
of studies, but reported neither the reliability nor the
validity of this new scale. The authors used judges'
ratings as the only source of data and one variable to
determine what constituted a good hour.

This study reports the work of fifteen experienced
therapists, each of whom had two clients. The authors
subjected the third and fourth sessions for each dyad to
content analysis. There are several problems with this
study. The patient population was poorly differentiated.

The therapist population was adequately described, but no

effort was made to distinguish between the effects of
the different types of therapists in the results.
The variables used to rate the tapes were listed but
the judges gave no operational definitions for them.
The authors used the variable for determining the
occurrence of a good hour, Therapist Responds Effect-
ively to Patient's Main Communications, but seem to have
chosen it arbitrarily with no attempt to fit it into
any major theoretical frameworks of psychotherapy.
Finally, the two authors admit, they have

"no outside criterion for the validity

of our ratings of this variable--or

for any of our other ratings" (p. 163).
Auerbach and Luborsky examined and reported inter-judge
reliability on this central variable, which ranged from
r=.47 to r=.65 for comparisons among the three judges.
Reliabilities for inter-judge ratings were reported for
all variables, but the reliabilities were performed upon
the research materials used and calculated afterwards.
The total inter-judge reliabilities, however, were not
mentioned.

Of the 60 sessions rated for Therapist Responds
Effectively, the top 18% (10 sessions) were classified
as "good hours" and the bottom 18% (11 sessions) were
categorized as "poorer hours." The authors found the
following variables to be significantly different when

contrasting the two groups of sessions, in descending

order of difference: Therapist Skill, Therapist Empathy,
Therapist Unconditional Positive Regard, Therapist
Security and Maturity, Therapist Warmth, Therapist Crea-
tivity, and Therapist Emphasis on the Unconscious.
Though the authors made an attempt to clarify these terms,
they offer no real operational definitions. No patient
variables showed significant differences when these two
groups of sessions were compared. The authors concluded
by describing their general conceptions of better and
poorer hours. The conclusions drawn are clearly equivocal.
The final study on the "good therapy hour" was done
by Orlinsky and Howard (1967). They used 17 experienced
therapists and 60 female patients with the numberof
Sessions ranging from 8 to 26. The diagnoses for the
patients and the professional status of the therapists
were reported, but the authors made no attempt to differ-
entiate between the effects of these variables within
either of these groups in their results. The Therapy
Session Report was administered to all patients and
therapists after each session and this was the sole source
of data. No observers or other outside judges were used.
"Good” sessions were those rated high on a single
item of the Therapy Session Report. The practice of
using only one item is methodologically weak since both
the reliability and validity of this single measurement

procedure tends to be low. Orlinsky and Howard correlated

the ratings from all of the other variables with this
one item to determine what occurs in a good session.
They found that in terms of dialogue, or content, good
sessions (agreed upon by both the patient and ther-
apist) correlated with the patients' discussion of
Childhood Relations with Parents, Family (at the p:.01
level) which the authors say "suggests the importance-
of a genetic or developmental focus" (p. 624). In
addition, the therapists' ratings of the patients'
expressions of Sexual Feelings and Experiences, and Feelings
About Being Close or Needing Someone correlated with a
good session at the p:.01 level of significance. Both
patients and therapists valued sessions in which the
patient was interacting, friendly, affective, emotionally
involved, and in which the therapist was effective
(p:.05). Summarizing the relationship present in a good
hour Orlinsky and Howard state,

"Were we to characterize the general

tone of the relationship in good ther-

apy hours, we might describe it as one

of deeply felt actively collaborative

engagement--and, if not in the nature

of their respective tasks, then at least

in the style of relating, a relationship

between equals” (p. 626).
They also note that these results contradict both the
psychoanalytic and client-centered models of psychotherapy.

For the range of variables that the authors describe

as the feeling process, both members of the dyad agreed

that in good sessions the patient tended to feel likeable,

accepted, relieved, alert, interested, trusting, and
optimistic (p:.01), and the therapist tended to feel
effective, cOnfident, satisfied, Optimistic, alert,
interested, involved, close, intimate, sympathetic,
tender, and pleased (p:.01). Patients tended to rate
good sessions as ones-which were globally characterized
by positive affect in themselves, while therapists
valued sessions in which both positive and negative
affect emanated from the patient.

With respect to the cluster of variables that
Orlinsky and Howard call the exchange process, in good
sessions the patients describe themselves as expressing
a desire to work in person-to-person collaboration with
their therapists, to gain insight into themselves, and
to show positive gains. In these same sessions the
therapists saw their patients as seeking insight, not
being evasive or withdrawing from person-to-person con-
tact, not filling time simply in order to get the session
over, and desiring attention, approval, sympathy, or
affection. The therapists' goals in working with their
patients in good sessions were increasing their patients'
insight and supporting their patients' self-esteem. The
patients in good sessions felt satisfied for all nine
variables listed.

For session development, the correlations of these

items with good sessions were the highest of all items.

10

For both patients and therapists the patients' per-
ception (focusing on own concerns), performance
(communicating freely), and consummation (sense of
progress with problems) correlated at the p:.001

level, with motivation correlating at the Pi-01 level.
Both also agreed that for these sessions the therapists'
perception (empathy and understanding), performance
(helpfulness), and consummation was at the p:.001 level
of significance. _

The results of this study of good sessions are the
most descriptive and most important of the three per-
formed in this area, and, perhaps, the most applicable
to the notion of "critical;session." The limitation of
the reliability of the instrument, the lack of objective
data, the narrow sample of patients, and the lack of
data concerning specific types of patients with specific
therapists, however, qualifies the conclusions that can
be drawn from this research. It is, nonetheless, a good
beginning into the examination of what essential ingred-

ients characterize good or important sessions in the

process of psychotherapy.

The Value of This Study

 

One of the main difficulties blocking progress in
the field of psychotherapy research has been the approach
to empirical investigations employed by most of the

researchers. According to Bergin and Strupp (1972):

11

"The problem of psychotherapy
research in its most general terms,
should be reformulated as a standard
scientific question: What specific
therapeutic interventions produce
specific changes in specific patients
under specific conditions? In order
to answer this ultimate question it
is essential to achieve greater clar-
ification of the nature of the thera-
peutic influence and its effect by
implementation of empirical inquiries"
(p. 8).

The research here presented is an attempt to explore
the nature of the conditions under’which a very important
or "critical seSsion" will occur. Specific behaviors
and reactions on the therapist's part along with specific
actions emanating from the client, and the specific modes
of interaction between them will be examined. The setting
for a "critical session” will be made specific via the
utilization of a definite operational definition for
determining when a "critical session" occurs and which
will be based upon very specific criteria. Meltzoff
and Kornreich (1970) ask

"What are the important aspects or dimen-
sions of the relationship between patient
and therapist in the psychotherapeutic
situation? There have been few systematic
studies of the entire therapeutic relation-
ship, few attempts to map the important
connections between patient and therapist.
The next question is: important for what
reason? Since the ultimate issue is out-
come, many of the studies do have outcome
referents, implicitly or explicitly. How-
ever, within the immediate psychotherapeutic
situation, there may be a host of variables
that are intimately related to relationship
variables. It is possible that these complex
relationships change at various stages in a
psychotherapeutic series" (p. 453-454).

12

This study attempts to satisfy some of the
criticisms and follow some of the reasoning put forth
by Meltzoff and Kornreich in this statement. A
"critical session" might be the point at which "the
important connections between patient and therapist"
reach some climax or high level of intensity. At the
very least it can be said that these connections must
be present in such sessions in order for them to be
critical or very important in the process of therapy.
Hopefully, these connections will become clearer upon
the empirical examination of the variables inherent in
them to be undertaken by this research. In addition,
this study attempts to explore in a systematic fashion
the relationship variables involved in the process of
psychotherapy and to view how these variables change as
the process progresses from one stage to another. This
study assumes that a "critical session" signals the
passing of one stage and the entering into of another
stage in the therapeutic relationship. By contrasting
the results of the content and process analyses from the
sessions preceding and following a "critical session" in
this study, stages in psychotherapy may be demonstrated
empirically to exist as well as the measurable manner in
which both the process and the relationship in psycho-

therapy do indeed change.

13

What is the value of any study of psychotherapy
which does not deal with outcome per se? Kiesler
(1966) argues that outcome and process in psychotherapy
are so interrelated that one cannot study one without,
in effect, studying the other. On a slightly different
but equally germane tack, Bergin and Strupp (1972)
suggest,

"It is'. . . advisable to complement
controlled experimentation . . . by
continued naturalistic observation.

Such studies should employ one of the

more promising content-analysis schemes

as a tool for exploring systematic re-

lationships in the communications of the

two participants, even if the resulting

indices can not immediately be related

to therapeutic outcomes" (p. 39).
The main thrust of these arguments is that the investi-
gation of the process of psychotherapy is valuable in
its own right, regardless of whether it is related to
outcome. Surely a great deal can be learned from the
examination of the process of therapy and the therapeu-
tic relationship in a systematic and empirical manner.
Such knowledge also appears to hold great promise for
its application to the practice of psychotherapy, since
therapists could then learn to apply specific behaviors
in order to achieve specific therapeutic outcomes in
their work.

Following many of these ideas and recommendations,

this research will attempt a first step in examining the

nature of a very important "critical session." This

14

study will use a content-analysis instrument and a
process questionnaire to explore the changes that

take place around a "critical session" by analyzing

the therapeutic relationship and the conjoint processes
before, during, and after such a crucial session. Data
will be collected on the specific techniques and behav-
iors manifested by the therapist in his or her attempt
to influence the client and on the client’s attempt to
gain aid from the therapist. This study will also
examine the reciprocal impact that both client and
therapist exert upon one another at the point when this
impact becomes most amenable to observation due to the
heightened intensity of the therapeutic relationship.
The value of this research is best demonstrated by the
production of data about a specific situation in psycho-
therapy judged by many therapists to be of great impor-
tance in the process and which analyzes the specific

behaviors of both the therapist and the client.

Review of the Literature on the Nature of a "Critical

 

Session"

While "critical sessions" in psychotherapy have
often been described, they are most often employed by
the writers as "clinical vignettes to concretely depict
some specific point. Rarely does the literature on
psychotherapy theories offer references to "critical

sessions" or critical incidents as they relate to the

15

process of therapy. Even sparser, are references to
their relation to the basic constructs of any of the
schools of psychotherapy. A few theorists refer to
critical incidents in passing, but most make no specific
mention of such occurrences and their place in the pro-
gress of the therapeutic relationship; some allude to
the notion of critical situations, and only one set of
authors actually describes in theoretical terms the
various facets of a "criticalssession."

Several writers have specifically referenced
critical incidents in their descriptions of individual
case reports. Frankl (1959) describes a critical inci-
dent as the relationship between the therapist and the
client growing into a fully human encounter which was
not merely an emotional one but a totally existential
relationship between two persons. According to Frankl,
it is the point at which the therapist and the client
become two partners. Snyder (1959) says-that the real-
ization that one is the recipient of a deep and sincere
“love“ has been demonstrated many times to be an exper-
ience that is entirely capable of modifying one's life-
style. Finally, Sorokin (1959) describes the critical
point as the moment when the therapist shows "real
concern, friendship, or altruistic love" and the patient
becomes "convinced of this" and feels it "with his total

personality." While they point in a definite direction

16

these brief descriptions of a critical incident or
"critical session" seem either too vague, too general,
or too simplistic to explain fully the nature of the
events and the changes in the process. However indef-
inite, these scant passages are some of the best
descriptions available in the theoretical literature
concerning "critical sessions."

Only in a hypothetical manner can the main aspects
of a "critical session" be derived from the literature.
In terms of psychoanalysis, a "critical session" may be
one in which the therapist interprets some resistance
to the client, who responds by revealing the relation
of that particular resistance to a deeply-rooted problem
in his personality or connects it to some central id
impulse seeking discharge.

Such an interpretation might include Greenson's
(1967) method of confronting resistance in a patient,
especially a resistance emanating from the patient's
transference. The result of such an interpretation
might be a deeper exploration of the patient's person—
ality and problems in which the patient becomes both
‘experimentally and behaviorally more cooperative in
examinaing these newly uncovered dimensions of himself.
Such cooperative enterprise could also entail a feeling
of closeness and involvement on the part of the patient

and the therapist. Similarly, a therapist's interpretation

17

of a major portion of the patient's transference feel-
ings may combine with a re-orientation toward reality
regarding who the therapist really is and toward whom
the transference feelings and behaviors are actually
directed. This may also bring about a similar result of
cooperation and closeness in the analytic setting.

It is also possible that either interpretation may
not bring about these positive feelings in the client
during a "critical session," that the result may be
negative or neutral feelings on the part of the patient.
However, for the psychoanalytic model the essence of a
critical incident seems to rely on some dramatic change
in the patient's behavior, emotions, or cognitive
structure. Since an interpretation of resistance or
transference is the major tool of analysis, it is logical
to hypothesize that the therapist would have the greatest
probability of effecting a major change in both the thera—
peutic relationship and the process of therapy, which is
the key assumption underlying the concept of a "critical
session.? It must be empahsized, however, that no pub-
lished empirical evidence yet exists to either verify or
disprove this key notion, so this entire theoretical
construct derived from the psychoanalytic literature must
be viewed as a hypothesis.

Although far from the psychoanalytic model and using

very different terminology, Carkhuff and Berenson (1967)

18

describe essentially the same phenomena as those

above, when writing on the use of confrontation in
psychotherapy. They state that no real progress can

be made in therapy until the therapist confronts the
client on the maladaptive behaviors and the inappropriate
feelings he expresses in the therapy session. While the
terms they employ are different than the psychoanalytic
terms, the concept of interpretation of resistance and
transference as having a major impact upon the process

of psychotherapy and the relationship between the ther-
apist and client is clear. Their ideas seem to closely
parallel Greenson's constructs in that the personality
and the problems of the client can only be fully explored
if the resistances and transferences are interpreted,

or as Carkhuff and Berenson put it, are confronted
directly. The occurrence of such a confrontation could
be conceived of as a "critical session," since it fits

in well theoretically with the key assumption of a
"critical'session."

For the client-centered approach, a “critical
session" could theoretically be a time when the thera-
pist fully understands some important segment of the
'client's present experience in the session. The thera-
pist would have to be able to communicate this understand-
ing and his own experience completely to the client,

within Rogers' (1961) framework of empathy, genuineness,

19

and nonpossessive warmth (or unconditional positive
regard). Once the client, in turn, is able to experience
the therapist's understanding of him and the therapist's
own present experience within the-Rogers framework,

then a mutuality of experience would simultaneously
create a bond of closeness between the two and alter

the client's experience of the therapeutic situation

and the therapist more towards reality.

For this alteration to happen, Rogers (1961)
stresses the essentiality of congruence in the therapist's
feelings and behavior. This end product of mutuality is
accomplished in this model of psychotherapy not by inter-
pretation, but by the ability of the therapist to under-
stand and accept the client fully, to express this
understanding and the other necessary therapeutic condi-
tions in a genuine manner, and for the client to accept
the therapist's understanding and caring as real. If all
this can be achieved, the process of therapy can truly
proceed toward healing, for the relationship between the
client and therapist has changed toward one of greater
cooperation based upon mutual caring and closeness. Such
an occurrence in the client-centered framework qualifies
as a "critical incident" or "turning point".

The theories of existential psychotherapy would
proceed in a manner somewhat similar to the client-

centered approach. May's (1958) conception of human

20

existence postulates that once the therapist, through
his therapeutic experience with the client, can aid
the client to accept his own sense of being, the rela-
tionship between the client and the therapist changes
as does the process of therapy. The result is in
essence Frankl's (1959) description of a critical
incident, because it would constitute a fully human
encounter forming a totally existential relationship
between the two persons.

The only empirically based findings which add to
the theoretical framework are contained in the studies
by Auerbach and Luborsky (1968), and Orlinsky and Howard
(1967). Both are concerned with the "good hour." Are
the components that constitute a "good hour" essentially
the same as those of a "critical session?“ The argu-
ment can be made that the variables are more intensely
manifested during the latter. When the variables of
the "good hour" are extrapolated to the extreme of a
"critical session," they may change qualitatively as
well as quantitatively. However, this is a reasonable
theoretical approach that can be tentatively maintained
until empirical research can demonstrate its validity or
falsity.

Since these two studies were reported upon earlier,
only the hypothetical extrapolations will be discussed

here: active participation by the therapist; accurate

21

and effective response by the therapist to the client's
verbalizations, which means accuracy in interpretation;
therapist's affective involvement and his expression of
warmth and acceptance; the exploration by the client of
intimate interpersonal relationships and self-experience;
and the successful cooperation of both persons in attain-
ing significant insights and resolving emotional conflicts
for the client. Much of the empirical data collected by
these two sets of researchers fits well with the "critical
session" concepts of (1) significant interpretations or
confrontations by the therapist followed by (2) a feeling
of goodwill, and by (3) a mutual collaboration in further
exploring the client's personality and conflicts.

By far the most comprehensive and elucidating theor-
etical work concerning critical incidents and "critical
sessions" in psychotherapy has been written by Kell and
Mueller (1966). They begin their discussion of critical
incidents by describing some of the variables that pre-
cede such incidences. They explain,

"When the client begins to experience some

of the feelings that he has defended against,
his projections, accusations, and anxiety

may substantially increase. The counselor
must recognize that the increased client
agitation is a critical incident along the
path of the client's changing, and that the
clients' awareness of disorganizing feelings
is precipitating the client's responses . . . .

The counselor Cmust keep] in mind that - - -
his participation in the relationship

is precisely to trigger this type of response
pattern and that this is a necessary ante-
cendent to client change" (p. 8).

22

Kell and Mueller feel that rising anxiety and agi-
tation in the client are the signs that a critical
incident is about to occur. Obviously, therapy process
has uncovered material closer and closer to the client's
basic conflicts that causes such anxiety. They see a
"critical session" not as an isolated event, but rather
as a culmination of a chain of events triggered off by
the continuing exploration of the client's personality
and defenses. The client's desire for help and change
becomes balanced by his resistances to the loss of his
defenses and‘the uncovering of anxiety-producing material.
Kell and Mueller state,

"The client's eliciting behaviors continue
to have both facilitating and impeding
effects on the counseling relationship
throughout its course . . . critical
incidents will occur at those points
where the counselor is confronted with
the client's contradictory intent to
destroy the relationship" (p. 9).

They continue,

'"The budding signs of defensive resistance
in a client create critical incidents in
the counseling relationship since these
are the moments in the process when the
client's defenses and conflicts are most
likely to be activated . . . Resistance
will substantially increase as the client's
defenses are weakened, and the basic con-
flicts begin to rise to the surface"

The resistance of the client increases as the impact
and import of the therapeutic relationship increases

for the client. When the intensity of the therapist-client

23

relationship peaks, a critical incident or "critical
session" occurs because the transference and resistance
of the client have also increased. These must be con-
fronted by the therapist if therapeutic progress is to
follow. Kell and Mueller explain,

"When the relationship reaches high intensity
. . . the client is most vulnerable; for the
intensity reflects the significance of the
relationship. Whether change occurs in a
client is a function of how well the partici-
pants surmount the critical incidents that
arise when the relationship has reached this
level . . . At those decisive times where the
counseling relationship is intense and the
client's confrontation reaches into the depths
of his conflicts, we have noted not only that
a client's conflicts are most active and clear,
but that the conflicts are experienced and
expressed in a compressed way." (p. 33).

Implicit in-their statement is the need for the
therapist to interpret the client's transference and
resistance, or confront him with his inappropriate or
maladaptive behaviors and affects. Without such a move
from the therapist, the client will continue to exper-
ience his conflicts in "a compressed way" and have his
anxiety heightened even further by his lack of under-
standing of what his actions and emotions are and what
they mean. Only insight prompted by the actions of the
therapist will enable the client to achieve some measure
of assurance and control over his emotional experiences
in therapy, so that he can continue to work cooperatively

with the therapist in further explorations of these

24

conflict-laden areas. The maintenance of trust in the
therapist is an important ingredient if therapy is to
progress.

Mueller (1974) also sees several other results
emanating out of a "critical session." There will be
some changes in the client's perceptions of the thera-
pist, the client will accept the therapist as a more
caring person, and some of the client's distortions in
his view of the therapist and in his world view will be
corrected if the therapist handles the "critical session"
in a direct and proper manner.

Mueller postulates a number of effects that will
occur in the therapy sessions following a "critical
session": the client will experiment more with the
behavior worked on or with a living out of the conflict,
the client will be able to approach the conflict with
greater ego strength than previously, the client will
achieve insight faster concerning the emotional condi-
tions surrounding the conflict, the client will experience
more freedom to become anxious and as a result will bring
up more anxiety-provoking material about the conflict,
the client will produce more symbolism about the conflict
and the client will report more problems about that con-
flict as a result of working on it on a deeper level.
Mueller claims, however, that there may also be some

negative side-effects following a "critical session."

25

The client may feel guilty, anxious, or depressed as a re-
sult of confronting the conflict. Termination of therapy

by the client might even occur if his anxiety becomes too
diffuse to focus on that conflict again or if he is not will-
ing to face that much anxiety again. All of these theoretical
considerations are based upon Mueller's clinical experience,
and as with the other theoretical formulations, it needs

empirical verification.

Theoretical Definition of a "Critical Session"

A general theoretical definition can be composed for a
"critical session." It appears to be the appropriately timed
interpretation or confrontation by the therapist concerning a
significant set of behaviors, feelings, and cognitive per-
ceptions of the client. The client must eventually in the
session be receptive to the offered interpretation, with the
result being a mutual feeling of closeness and comradeship
leading to further deep explorations into the client's per-
sonality or central conflicts. In addition, the client must
feel understood and accepted by the therapist as a precondi-
tion for further progress in therapy. The client will leave
the session having felt some significant emotional impact,
having had some major cognitive reorganization, and having
perceived the therapist in a more realistic manner. As a
result both the therapeutic relationship and the process of

psychotherapy will have undergone a major change.

METHOD

The main purpose of this study was to identify
"critical sessions" in individual adult psychotherapy, and
to measure the relationships between the effects of these
sessions and the affective states of the clients empiri-
cally. The theoretical definition for a "critical session"
includes the criteria that the client will have felt some
significant emotional impact, and that this emotional im-
pact is the affective basis required for the exploration
of the client's central conflicts, his or her cognitive
realizations, and his or her new perceptions. Thus, exam-
ining the degree of this emotional impact should provide
an important measure of the change in the therapeutic
process. It is intended that the measurement of the
presence and intensity of client affect before, during,
and after such a "critical session" will provide insight
into the way in which the target session has changed the

therapeutic relationship from the client's perspective.

Operational Definition of a "Critical Session"

Implicit in the theoretical definition for a "critical
session" are the requirements that some of the client's
central conflicts had been confronted and explored during

the session; that the therapist and client achieved a mutual

26

27

feeling of closeness; and that the client had experienced
some significant emotional impact, achieved some major
cognitive reorganization, and perceived the therapist in
a more realistic manner. Obviously, it was necessary to
translate this general theoretical definition into an
operational definition suitable for an empirical study.

Because neither the research nor theoretical litera-
ture defines a "critical session" in operational terms,
such a definition had to be created. A survey of exper-
ienced psychotherapists provided this definition. They
were asked what variables might constitute a “critical
session” in individual adult psychotherapy. For the
purposes of this survey an experienced psychotherapist .
was defined as a person who has had at least two years of
experience performing individual psychotherapy with adults
after either earning a doctoral degree in psychology or
finishing a residency in psychiatry.

A preliminary interview survey of five experienced
psychotherapists at Michigan State University provided the
variables which were included in this survey, called the
Psychotherapist Survey Questionnaire (PSQ). All variables
were operationalized and then listed in the PSQ under an
introductory statement on the theoretical conception of a
"critical session." This questionnaire was sent to 62
experienced therapists across the United States. The

variables chosen by the respondents to be of greatest

28

importance during a "critical session" were used in form-
ulating the final operational definition for a "critical
session." The results of this survey and the process by
which these results were converted into an operational
definition for a "critical session" will be found in the

Results section (pp. 49-54).

Hypotheses

 

General Hypothesis. It is hypothesized that there is a
relationship between therapy sessions clients identify
as "critical" and the degree to which the client's central
conflicts have been confronted and explored, the therapist
and the client have achieved a feeling of closeness, the
client has experienced some significant emotional impact,
the client has achieved some major cognitive reordering,
and the client has perceived the therapist in a more real-
istic manner.

Two specific hypotheses follow the preceding general
hypothesis.*
Hypothesis 1. That there will occur a change in the
client's report of his or her affect from the session
immediately preceding a “critical session" to the session
immediately following a "critical session," with that
change being measurable by the Multiple Affect Adjective

Check List (p:.05). It is predicted that these statisti—

 

‘For the purpose of setting forth the hypotheses, the term
"critical session" will be used to indicate the session
under study.

29

cally significant differences will occur over the three
indicated sessions for each of the following subscales
of the MAACL: (a) Anxiety scale, (b) Depression scale,
(c) Hostility scale.
No prediction is hypothesized regarding direction
of change in these subscales. Available theory concern-
ing the nature of,a "critical session,” its effects upon
the process of therapy, and the affective state of the
client does not sufficiently permit meaningfulpredictions.
In fact, current clinical theory is so ambiguous concern- '
ing the expectable effects Of a "critical session" that
speculation about the possibilities can cover a wide range:
(1) 'Expression of affect by a client during a
"critical session" involving a central Conflict
might increase the client's anxiety. On the other
hand, the fact that the client has been able to
express some of the affect involved in that con-
flict may also alleviate some of the anxiety that
was previously connected with the suppression of
that conflict. Consequently, it seems equally
justifiable to predict a change in either direction
on the client's score on the Anxiety scale of the
MAACL following a "critical session."
(2) As the client begins to face his or her con-
flicts and the suppressed emotions surrounding them,
the affects measured by the Depression scale of the

MAACL may decrease. Here, too, the opposite could

30

occur, if the client's reactions or resistances to

dealing with the conflict and affects precipitated

in the “critical sessiOn" invOlve an increase in
the affects in the MAACL DepreSSion scale.

(3) The nature of a."critical session" may cause

the client to feel a sense of warmth and closeness

toward the therapist, with a resulting decrease in
client hoStility. 'The client's central conflict,

_however, may involve the expression-of hostility

which serves to increase the client's score on the

Hostility scale of the MAACL. In addition, the

client's ambivalence over directly facing these

affects and conflicts may activate and add impetus
to the client's psychological defenses against the
feelings of warmth and closeness with the therapist.

_This ambivalence can result in an increase in

expressions of withdrawal or hostility, or of both

theSe defensive reactions by the client.

In light of these theoretical considerations, the
most reasonable course appeared to have been to leave
the directionality of the predicted changes open.

A cross-check on the client's reports of his or her
affects and on the process of therapy was made to provide
increased further data for examination in this study.
The therapist in each dyad completed the MAACL from the

point of View of the client. Consequently, an independent

31

judgment of the client's affects was made by an observer
who was trained to make such observations and judgments.
This cross-Check forms the basis of a Second hypothesis,
cOnceptually parallel to the first.

Hypothesis 2. That there will occur a change in the
therapist's report On a client's experienced affects from
the session immediately preceding a "critical session" to
the session immediately following a,"critical session,"
with that change being measureable by the Multiple Affect
Adjective Check List (p:.05). It is predicted that these
statistically significgnt differences will occur over the
three indicated sessions for each of the following sub-
scales of the MAACL: (a) Anxiety scale, (b) Depression

scale, and (c) Hostility scale.

 

.Subjects and Settings

The subjects to be analyzed in this study were ten
adults in individual psychOtherapy who each formed dyads
with practicing therapists. These therapists agreed to
participate in this research without compensation. The
clients_and therapists were selected from the Michigan
State University Counseling Center, the Grand Blanc
Mental Health Services outpatient clinic in Flint, Michi-
gan, the Beth Moser Mental Health Clinic in Jackson,
Michigan, and from therapists in private practice in
Michigan. The sessions took place in the offices of

these therapists.

32

Clients under 18 years of age or who were judged by
their therapists to be psychotic, schizophrenic, psycho-
pathic, or sociopathic, or who were nOt in individual
psychotherapy with a single therapist were excluded from
the subject pool. 'Therapists who had less than two years
of full-time work experience in psychotherapy since come
pleting either a doctorate in psychology, a residency in
psychiatry, or a masters' degree in social work were
eliminated from the subject sample for this study. Ther-
apists who practice any type of verbal psychotherapy except
those who performed behavior modification were eligible
for this study.

The sample size was too small to provide useful
statistical inferences based on demographic variables. The

collected demographic data is presented in Appendix L..

Instruments

 

The following measuring instruments were used in
this study:

1. Background Questionnaires (see Appendices B and C).
Two forms of this questionnaire were designed for this
study, one for the client and one for the therapist.
The client form gathered basic demographic information
concerning the client and data describing past and
present experiences with psychotherapy. The therapist
form collected personal information about the therapist

and data relevant to his or her role as a therapist. Each

33

person completed his or her own form.

2. Psychotherapist Survey Questionnaire (see
Appendix A). This questionnaire evolved from the in-
formal interview survey of psychotherapists at Michigan
State University (see Results section, p. 48-49). It
was distributed by mail to 62 experienced psychotherapists
in the United States, and was designed to elicit from them
opinions about the importance of various terms used to
describe a "critical session." The Psychotherapist
Survey Questionnaire (PSQ) consisted of.an'introductory
statement describing a general theoretical conception of
the "critical session," a list of eleven variables with
rating scales for marking importance for a "critical
session," and a space for adding another variable to the
list and rating its importance. An extra page was included
for describing a "critical session" if the respondent dis-
agreed with the initial theoretical statement.

3. "Critical Session" Questionnaire (see Appendices
D and E). This instrument was developed specifically for
this study. Its purpose was to identify "critical sessions"
as defined by the operational definition. The results of
this questionnaire can be found in the Results section, (PP-
54 - 57). Statistical analysis yielded three items that
the respondents to the PSQ chose as being most important

to a "critical session." These three PSQ items were:

VI.

IX.

34

Some conflict that the client has been
dealing with in a less direct or less
affect-laden manner gets confronted
directly.

Some material that the client was pre-
viously unaware of is brought into the
client's awareness in a way that is
useful to him or her.

Some cognitive reordering occurs in the
client so that he perceives the therapy
situation, himself, the therapeutic re-
lationship, or his world view in a differ-
ent way; some important insight is obtained.

These three PSQ items were formed into seven items

in the CSQ in the following manner. Item VI of the PSQ

became CSQ client form items 3 and 4:

3.

4.

During this session, were you able to talk
about one of your main problems directly?

During this session, did you express any
emotional feelings concerning one of your
main problems?

CSQ item 3 addresses the part of PSQ item VI which involves

whether one of the client's conflicts had been dealt with

in a direct manner. Item 4 of the CSQ expresses the come

ponent of PSQ item VI which deals with an increase in the

affect involved with one of the client's conflicts. Be-

cause many clients do not know or understand the esoteric

meaning of "conflict" as used by therapists, this word

was changed to "main problem." Although the terms "con-

flict" and."main problem" may not have been identical in

meaning,

it was felt that the latter term was the best

substitute for the former that could be used with clients

35

naive in the area of psychotherapy. It was also felt
that if the client expressed a great deal of affect
about something which he or she thought of as a central
problem, then the main elements of this variable had
been addressed.
Item IX of the PSQ became item 5 of the CSQ:
5. During this session, did you learn any new
and important things about yourself which
you will be able to use?
The idea of bringing material into the client's awareness
contained in PSQ item IX is expressed by the terms ”learn"
and "new" in CSQ item 5. The idea of usefulness from PSQ
item IX is stated directly in CSQ item 5 and is heightened
by the term "important."
PSQ item X was converted into four items in the CSQ,

6' 7] 8’ and 9:

As a result of the session you have just completed,
how do you view the following?

6. Yourself

7. The course of your therapy

8. Your personal environment

9. Your therapist
In all these translations it was believed that any theor-
etical language should be transformed into language a
layman could more easily understand. "Cognitive Reorder-
ing" was changed to the client's "view," since a change
in one's reported perspective appeared to be the best and

most clearly reportable substitute for the former term.

36

It was assumed that one's verbalized view of particular
events or persons (such as the therapist) reflects what
one thinks about or how one conceives of.those events or
persons. Because absolute precision in substituting
concrete terms for abstract ones is likely to be impossible,
it was hoped that a clearly understood term such as ”view"
would provide clients more useful information than the
more accurate but also more esoteric term "cognitive
reordering." Similarly, the term "the therapy situation"
became "the course of your therapy," "himself" became
"yourself,” "the therapeutic relationship" became "your
therapist," and "his world View" became "your personal
environment."

The therapist form of the CSQ contained the same items
as the client form, except for wording designed to elicit
the therapist's viewpoint. The therapist rated the client
on these items listed above.

Two additional items from the CSQ were included in
the core criteria for a "critical session." These are
items 1 and 2. Item 1 dealt with the client's feelings
about how "good" the session had been. Item 2 sought to
determine if the client felt the session had brought him
closer to his goals for himself in therapy. It was assumed
that the theoretical definition clearly contains both the
idea of having a good session and of making substantial

progress towards one's goals in therapy as necessary occur-

37

rences before the client could feel that the other elements
composing a "critical session" had occurred. It was
assumed that a "critical session" could not occur if the
client felt that the session had been "bad" or that no
progress had been made toward his or her therapeutic goals.
It appeared clear that these two variables would be neces-
sary concommitants to the other variables and would be
present in any session chosen as "critical," so these items
were included in the CSQ.

In addition, four free response questions designed
to gather further data on the session by having the client
use his or her own words were included in the client form
of the CSQ. It was assumed that the design of the CSQ
gave it face validity for identifying "critical sessions."

4., Therapy Session Report (see Appendices H and I).
This questionnaire.(Orlinsky and Howard, 1966b) was adminis-
tered in separate corresponding forms to both client and
therapist immediately after each therapy session over
consecutive meetings in order to examine the process of
therapy.

The Therapy Session Report (TSR) covers a wide range
of possible problems that might be experienced and dis-
cussed by the patient (Orlinsky, Howard, and Hill, 1970).
The concerns of the patient surveyed by the TSR were
taken from Erikson's (1950, 1959) formulations of the
nuclear ego-conflicts comprising the content of the psycho-

social crises in eight stages of the life cycle, and from

38

Sullivan's (1953) developmental scheme. In addition, the
developers of the TSR used their own clinical experience,
professional consultation, and pilot data to make the
questionnaire as widely applicable as possible. They
similarly attempted to cover a wide range of therapist
responses and initiatives in relation to these patient
concerns.

In their report on TSR's development, Orlinsky and
Howard (1967 a) say the TSR attempts to cover the follow-
ing facets of therapy experience:

(1) the topical content of the dialogue, as

established by the patient in each session; (2)

the nature of the relationship as reflected in the

patient's and therapist's manner of relating to

each other; (3) the joint affective process, as

embodied in the feelings experienced by patient

and therapist during the session; (4) the exchange

process, including the patient's wants, the thera-

pist's goals and the types of satisfaction contained
in the patient-therapist interaction; and (5) the
development of the therapy session as an inter-
personal act having its inception in the motivation
of each participant, its implementation in their

role performance, and its consummation in the greater

or lesser realization of their goals.

39

Orlinsky and Howard performed their major testing
of the TSR in their Psychotherapy Session Project (1966
a). They administered this instrument to 188 non-psycho-
tic female patients who completed it for a range of 5 -
66 consecutive outpatient sessions of individual therapy.
The 27 therapists, of whom 18 were male and nine were
female, completed questionnaires on from 5 - 64 sessions
for from 1 - 15 different patients. The therapists were
from all the professions engaged in psychotherapy, had
a median experience level of six years, and were "generally
dynamic-eclectic" in their orientation. From the data
collected in this major undertaking an extensive set of
analyses were performed in order to both validate the TSR
as an instrument and to provide information on the process
and content of psychotherapy.

Orlinsky, Howard, and Hill (1970) reported the
problematic concerns of the patients within their pro-
ject and analyzed these into seven factors that are
differentiated by the TSR. In addition, they related
the data associated with these factors as measured by
the TSR to prevalence of patients' problematic concerns,
correlation of therapists' impressions of patients'
concerns with listed patients' concerns, relation of
patients' concerns, relation of patients' concerns to
the developmental theories of Erikson and Sullivan, and

to the extent that patterns of concerns reflected stable

40

individual differences in contrast to session by session
variation. These same researchers in another study

(Howard, Orlinsky, and Hill, 1969) again utilized their
empirically collected data on the TSR to examine the
frequency of different topics discussed by patients in
psychotherapy, the major themes of these dialogues, indi-
vidual differences, and agreement between patient's and
therapist's report of the dialogue. Using this same data for
a third study, Howard, Orlinsky, and Hill (1970) analyzed TSR
results to explore typical feelings of patients and ther-
apists during a session, the major dimensions of affective
experience in therapy, agreement between the participants

in their perceptions of each other's feelings, and the
relationship between feelings and conscious problematic
concerns. Finally, Orlinsky and Howard (1967 b) used

their TSR research data to analyze the components of the
"good therapy hour."

The TSR has been expanded for use in this study, and
its main body of items has been slightly modified to
facilitate the examination of the content and processes
of psychotherapy in relation to the concept of "critical
sessions." These changes have been designed to identify
which of the items in certain sections of the TSR were
most important in that session. This identification has
been accomplished in the following manner for the client

form: (1) Added to the end of the section entitled, "During

41

this session I talked about:" has been the sentence, "Put
a check (/) in front of the subject from the above list
(items 2 - 21) that you talked about most during the ses-
sion," and‘(2) Added to the end of the section entitled,
"I feel that I got:" has been the sentence, "Put a check
(/) in front of the item from the above list (items 42 -
60) that best describes what you got most out of this ses-
sion." The same additions have been made to the therapist
form using the therapist's perspective. The client and the
therapist forms of the TSR are presented respectively in
Appendices H and I.

The additional items that were included in the TSR
were presumed to measure specific variables postulated
as being present in "critical sessions" by the theoretical
definition. These TSR items were: 56, 57, 58, 59, 60,
69, 70, 71, 72. The additions were made to both client
and therapist forms using their respective perspectives.

5. Multiple Affect Adjective Check List (see Appendices
F and G). This questionnaire consisted of 132 items which
composed three scales: Anxiety (A) scale, Depression (D)
scale, and Hostility (H) scale. The MAACL had the advant-
age of being easy to understand and administer; the subject
simply checked off which of the listed affects applied to
him or her in the time period specified in the instructions.
This check list was used to provide the quantitative data
for determining the differences in the expressed affect of

the client between the session preceding and the session

42

following a “critical session." For the purposes of this
study, an instruction to circle the one feeling that the
client felt most during the session has been added to the
MAACL.

The MAACL is a well-researched instrument. Its relia-
bility and validity have been repeatedly tested. The
present instrument began as the Affect Adjective Check
List (AACL) and was developed by Zuckerman (1960). After
empirical testing, two separate item analyses were per—
formed by Persky, Maroc, Conrad, and DenBreeijen (1959)
and by Levitt, DenBreeijen, and Persky (1960). Zuckerman
(1960) also reported on the original reliability and
validity studies that were done leading to the final
development of the Anxiety scale.

Zuckerman and his associates later modified the AACL
to become the MAACL. Zuckerman and Lubin (1965) deter-
mined population norms for the MAACL by selecting 200
normal subjects from a pool of 1200 job applicants and
stratifying these 200 subjects by age, sex, and education
to match the 1960 census distribution of these variables.
In their research they found significant differences at
the p:.05 level between this normal group and 259 psychia-
tric—patients for all three scales (A, D, and H).

Several validity and reliability studies have been
performed on the MAACL. Zuckerman, Lubin, and Robins

(1965) administered the MAACL to 266 patients in five

43

psychiatric hospitals and to 275 normal subjects. They
reported that "Most of the patient samples were signifi-
cantly higher than the normal samples on the A and D
scales," and it was added, with less consistent results

on the H scale. They also found that "Education, age,

and intelligence were not related to MAACL scales in the
patient samples." No sex differences were found in the
normal sample. In two samples of subjects ratings of
observed anxiety and hostility were "significantly re-
lated" to MAACL A and H scale scores respectively. They
further reported that "Both retest and split-half relia-
bilities were high for A and D scales in a patient sample;
only the retest reliability was high for the H scale . .
The MAACL scales tended to correlate positively and sig-
nificantly with the D, Pa, Sc, and Hs scales of the MMPI."
More recently, Bloom and Brady (1968) correlated MAACL
scale scores with both clinical ratings on anxiety, depres-
sion, and hostility performed by psychiatric residents and
with Beck's Depression Inventory on 82 female and 18 male
patients one day after admission to a psychiatric hospital.
They found that the D scale had an r=.66 correlation with
the results from the Depression Inventory, with a high
level of statistical significance (p:.001). Using a chi
square analysis, Bloom and Brady also analyzed the D scale
as being related to the clinical ratings (p:.005). These

results lend content validity to the D scale of the MAACL.

44

Two studies demonstrated high reliability for the
MAACL. Zuckerman, Lubin, Vogel, and Valerius (1964)
administered the MAACL three times over a period of
three weeks to 46 normal college students in order to
obtain some base-line data. They obtained Spearman-Brown
reliability coefficients of r=.79 for the A scale, r=.92
for the D scale, and r=.90 for the H scale, with all of
these results being significant (p<.01). Herron (1969)
reported reliability coefficients—Of from r=.64 to r=.82
for the total MAACL over three administrations over a
four week period using 33 normal college students, indi-
cating a high degree of at least short-term stability.
These researches have suggested that the MAACL is both a
valid and a reliable instrument for measuring affect,
making it suitable for measuring the dependent variable

in this study.

Procedure

 

This study used ten client-therapist pairs with each
pair permitted to contribute only one ten session set.
An effort was made to have half of the dyads begin therapy
concurrently with the research, while the remainder entered
the study after having completed ten or more sessions.
Neither clients nor therapists were informed of the
specific nature of the study. Therapists who volunteered
for participation in this study chose from among their

caseload one client who fulfilled the requirements of this

45

study.(see Appendix J). All participating clients and thera-
pists completed their respective forms of the Background
Questionnaire. These data are presented in Appendix C.

At the end of each of the sessions encompassed in
this study both the client and the therapist completed
the "Critical Session" Questionnaire, and the Therapy
Session Report, and the Multiple Affect Adjective Check
List. All these instruments were completed by the parti-
cipants from their own individual points of view, except
for the therapists who completed the Multiple Affect
Adjective Check List as if they were the particular client

with whom they had just finished the session.

Selection of an Operationally Defined "Critical Session"

for Analysis

 

The items which were judged by most experienced
therapists to be of greatest importance in "critical
sessions" on the PSQ formed the core criteria for de-
termining that a particular therapy session was a
”critical session." The procedure for selecting "criti-
cal sessions" was as follows.

The "Critical Session" Questionnaire was the sole
instrument used for measuring the variables chosen as
important by the surveyed psychotherapists. The client's
ratings on CSQ items 1 through 9 were used in selecting

"critical sessions." For each of the therapy pairs the

46

session which exhibited the highest median score for the
client's ratings on items 1 - 9 of the CSQ and in which
at least seven of the nine scores were greater than or
equal to +2 was operationally defined as a "critical
session."

Of the ten subject dyads, at least five had to con-
tain an operationally defined "critical session" because
this was the minimum number with which a statistical
analysis could have been useful. Eight of the dyads met
the criteria of the operational definition for a "critical

session."

Statistical Procedures

A three-way analysis of variance was performed upon
the data obtained from each of the subscales of the MAACL
for each dyad. Statistical significance was determined
using a one-tailed test (p:.05). Sessions preceding and
following the "critical sessions" were compared with each
other and with the "critical sessions." These three types
of sessions were also compared with three consecutive
randomly selected sessions from each of the dyads which
showed "critical sessions." These randomly selected
sessions served as controls.

In addition, the TSR results were examined in an

exploratory manner in order to determine if there were

any other relationships to be found among the various

47

dimensions outlined in the theoretical definition for a
"critical session." Three items selected on an a priori
basis from the TSR which specifically related to the theor-
etical definition (items 49, 56, and 59) were statistically
analyzed using a three-way analysis of variance. This exam-
ination was predominantly aimed at uncovering some of the
components present in “critical sessions" in an exploratory
way; a greater number of TSR items would have been subjected
to statistical analysis had any significant findings (p:.05)

emerged in the results of the statistical analyses of the

first three TSR items.

RESULTS

The object of this study was to identify and examine
"critical sessions" occurring in the process of psycho-
therapy. Because neither the research nor theoretical
literature contained an operational definition for a
"critical session," such a definition had to be created.
The operational definition for a "critical session" was
constructed by: (1) using an informal survey to collect
data on the nature of "critical sessions," (2) using
this data to formulate the items on the PSQ, (3) sending
the PSQ to 62 experienced psychotherapists, and (4) using
the data collected from the 46 respondents to the PSQ to
choose variables for inclusion in the CSQ.

Results of interviews with five psychotherapists
(with at least ten years of experience), which consisted
of the therapists' reactions to the concept of "turning
points" and "most important sessions", became the corner-
stone of this study. Four of the five felt that "critical
sessions" as described to them do exist. One therapist
felt that all sessions were equally important, and that
there were no "turning points" in therapy. The four
.therapists who gave a positive response were asked to
describe the processes occurring during a "critical

session." All of the processes described by

48

49

these four therapists were converted into PSQ items I
through XI (see Appendix A). The wordings of these
therapists were kept intact as much as possible.

The PSQ was sent to 62 experienced therapists and
researchers throughout the United States in order to
obtain their views on what variables and processes might
be present in a "critical session" (i.e., if.they
agreed that such sessions exist). For the purposes of
this survey an experienced psychotherapist was defined
as someone who has had at least two years of experience
in individual psychotherapy with adults after having
earned a doctorate in psychology or having finished a
residency in psychiatry. In addition, actively publish-
ing researchers in the field of psychotherapy who also
practiced therapy were chosen to be part of the survey
regardless of length of experience. It was felt that
experienced persons in both of these areas would have
knowledgeable viewpoints concerning psychotherapy and
would be able to provide construct validity to the infor-
mation collected based upon their expertise. The only
group eliminated from potential respondents because of
their theoretical viewpoints were those who practiced
behavior modification.

The response rate to the PSQ survey was high; 52 of
62 (84%) responded. Forty-six persons (88%) responded

to Part 1, including 40 psychologists and six psychiatrists.

50

Together they had a mean experience level of 14.4
years. Six additional persons (12%) chose to respond
to Part 2, rejecting the idea of "critical sessions."
Of the ten who did not respond three persons were
deceased and seven chose not to respond for unknown
reasons.

The median rather than the mean was employed for
each set of responses to a PSQ item to eliminate the
effects of extreme responses. The medians for the

responses to the items in Part 1 of the PSQ were as

 

follows:
PSQ Question No. Median
x ‘ 8.0
IX 8.0
VI .. 8.0
I 5.5
IV 5.0
III 5.0
VII 4.0
II 3.0
XI 2.0
VIII 2.0
V 0.0

The medians for only three of the items, VI, IX,
and X, fell within the range of "extremely important" for

a "critical session." A one-tail t-test performed on the

51

PSQ responses revealed a highly significant difference
(p<.0005) between the responses for items VI, IX, and X
and the PSQ responses as a whole.

The PSQ results also yielded a number of ideas and
concepts concerning the nature of "critical sessions"
from the 46 respondents to Part 1. Item XII was an
optional item consisting of a free response along with
a rating of its importance. Ten of the respondents to
Part 1 completed this item. Their responses and ratings
for item XII were as follows:

"There is a shift in how the whole thing feels. +10"
"Thematic flow - experiential flow enhanced; greater
depth in experiencing, peak experience in session.

+ 10"

"The client experiences greater self confidence,
power, feels he can be in charge of his life. +10"

"Client is willing to face the problem more directly
and take the initiative. +5"

"The client experiences, acceptant1y* (*as a part
of himself which he can accept), a feeling pre-
viously denied to awareness. +10"

"Therapist's perception of client is changed; new
insights and understandings about client is felt
by the therapist. +10"

"The client's trust of the therapist increases sig-
nificantly (which provides him with the willing-
ness to expose himself to greater anxiety). +10"

"The client recognizes his mortality and finiteness.
+8"

"An affective-cognitive realization on the part of
both therapist and client that somehow rearranges
the pieces of the puzzle in a new way, that is
both freeing and challenges the client to further
self discovery. +10"

52

"Previous insights merge and heighten the potential
for behavior change. +10"

While most responses to item XII indicated that a
change of some sort takes place in the client, as can
be seen,the opinions on the nature of this change vary
widely. Some of these responses also focused on changes
in the therapist or client's feelings toward the thera-
pist. Because there was so little correspondence among
these free responses, none was included in the CSQ. These
ideas were noted, however, and are examined in more
detail in the Discussion section.

Six respondents rejected the concept of "critical
sessions," and listed their explanations in Part 2 of the
PSQ. The reasons, summarized in the language used by
the respondents are as follows:

(1) Sessions that were seen as "critical" or "very
important" at the time of the occurrence of the session
may not seem so at a later time; sessions that seemed no
different in their importance at the time may be judged
to have been significant at a later time. What may appear
significant may not be; what may appear not crucial may
be.

(2) Often the most crucial session is the first
one, even though very little may appear to occur.

(3) What are described as "critical sessions" in
the PSQ introduction may only be "summative" sessions,

in which the important processes which led to these

53

sessions are only recognized or verbalized in a more
intense or climactic manner. The more crucial processes,
content matter, or events may have taken place in less
dramatic "formative" sessions which are preparation for
these "summative" sessions.

(4) Part 1 of the PSQ did not cover the full range
of processes which are necessary to client change and
"critical sessions" as described do not cover the crucial
processes of therapy. Merely experiencing feelings with
a caring therapist is not sufficient; the client, to
progress, must acknowledge these feelings, bear them,
overcome his or her defenses, and put these feelings in
perspective with the rest of life. While a ”critical
session" may help to accomplish this, it is only one
step in the full process.

(5) Much of the "therapeutic work" goes on between
sessions, with this work possibly being more important
than the work within interviews.

(6) There may be a number of "important“ sessions
which contribute to therapeutic progress, rather than a
single "critical session."

One respondent to Part 2 did not disagree with the
definition of a "critical session," but felt that he
could not respond to the choices in Part 1 because they
had not been made in terms of a particular presenting

problem of a particular client. He felt that the "general"

54

case did not get at the issues involved.

Ten client-therapist dyads participated in this
experiment and completed the CSQ, the MAACL and the TSR
after each of ten consecutive sessions. A dyad was con-
sidered to have had a "critical session" if: (1) there
was a single greatest median in the positive direction
for the client's scores on the nine variables of the CSQ
for a single session, and (2) the scores of at least
seven of the nine variables in this single highest
session were equal to or greater than +2.

Eight dyads were determined to have had a "critical
session" by this method, while.two did not. The results
of the data derived from the CSQ are presented in Table l.

A t-test was used to compare the distribution of the
medians for all the scores on the CSQ with the distribu-
tion of the medians for the eight identified "critical
sessions." A one-tail t-test demonstrated that the sample
medians differed from the population medians at a highly
significant level, t(100)= 9.881, p<.0005. These results
indicate that the "critical sessiohs" identified by the
CSQ were, as a group, significantly different than the
group of other sessions, including the sessions from the
two dyads which did not have a "critical session."

This research was originally designed to provide an
approximately equal distribution between beginning of

therapy dyads and middle or end of therapy dyads.

TABLE 1

55

Results of "Critical Session" Questionnaire

(Client Form)

 

No. of Median for Number of Scores >+2
Dyad Sessions Client's Scores* For "Critical SessIOn"**
$1 10 + 3.9 3
$2 10 + 3.0 7
s3 10 + 4.6 3
S4 10 + 3.1 9
ss 10 ‘+ 3.1 8
$6 10 + 3.9 7
S7 10 + 3.8 9
$8 10 + 3.8 9

 

*The scale for each item ranges from -5 to +5. The

highest possible median is +5.0.

**There are nine items in the questionnaire making for a

maximum of nine scores.

56

However, because the therapists chose what they felt to
be appropriate clients, this equal division was not
achieved.

The therapists also chose the session with which
to begin participation. They were strongly encouraged
to start at either the first session or at some session
after the tenth, so the beginning and middle or end of
therapy process could be examined. Due to the difficulty
of obtaining willing therapists and clients, however, a
flexible starting point was eventually permitted. This
resulted in a maximum number of participating dyads.

For the ten dyads, the study commenced at the follow-
ing session numbers: 1, ll, 16, 18, 18, 25, 44, 45, S3,
55. If the beginning phase of therapy can be considered
to extend arbitrarily to the 20th session, five dyads
fell into this category. The middle or end of therapy
range was broadly distributed.

The "critical sessions" identified by this study
could not be pinpointed as occurring during one particular
phase of therapy (i.e., beginning, middle, or end of
therapy). The two client-therapist pairs who did not
achieve a "critical session" were the dyads which started
at session 18 and session 55. "Critical sessions" were
equally divided between the dyads which commenced prior
to the 20th session and those which commenced after the

20th session. The eight identified "critical sessions"

57

appeared at sessions numbered 10, 15, 21, 21, 28, 49,
53, 56. These data are presented in Table 2. The
distribution of these "critical sessions" defies even
a rough grouping, with no estimate of where "critical
sessions" would most likely occur being possible.

The dependent measures selected for this study were
the three subscales of the MAACL. A separate three-way
analysis of variance was performed for the data collected
by each of the three subscales, the Anxiety, Depression,
and Hostility scales. Statistically significant results
at the p:.05 level were determined to be necessary in
order t; reject the null hypothesis. The MAACL data from
six sessions of each client-therapist pair were used in
the analysis of variance.‘ These six sessions were: the
"critical session,? the session preceding the "critical
session," the session following the "critical session,"
and three consecutive sessions prior to the "critical
session" chosen at random. The three randomly chosen
sessions were employed as controls with which to compare
changes occurring over the three sessions in the
"critical session" grouping to determine whether or not
these changes occurred by chance. The three levels
examined in the various 3 x 2 x 2 analyses of variance
were: (1) the "critical session" grouping of three
sessions vs. the "non-critical session" or control

grouping of three consecutive sessions; (2) the session

58

TABLE 2

Starting Sessions and Occurrence of

"Critical Sessions" for the Therapy Dyads

 

 

Subject Session Number When Session Number for
‘Dyad Starting in This Study "Critical Session”

81 44 48

$2 11 14

$3 16 20

S4 18 . 20

SS 1 9

86 25 27

S7 45 48

$8 53 55

89* 18 --

310* 55 --

*Dyads S9 and 510 had no operationally defined "critical

sessions" occurring during the study period.

59

preceding the "critical session" vs. the first session
of the control grouping (the "before" EB] sessions), the
"critical session" vs. the second session of the control
grouping (the "target" CT] sessions), and the session
following the "critical session" vs. the third session
of the control grouping (the "after" [2;] sessions); and
(3) the clients vs. the therapists.

All three analyses of variance for the subscales
of the MAACL failed to produce any significant results
for any level or any dimension. The results of the
anlayses of variance for the three subscales of the MAACL
are presented in Table 3, Table 4, and Table 5. No major
differences were found in dependent variables between:

(1) the session preceding a "critical session" and the
"critical sessions" along any dimensions, (2) the
"critical session" and the session following a "critical
session," or (3) the "critical session" and a randomly
chosen control session.

An additional set of three-way analyses of variances
was performed for each of the three items in the Therapy
Session Report chosen for their relevance to the theoreti-
cal definition for a "critical session." Three TSR items,
49, 56, and 59, were selected because they directly per-
tained to the client's experiencing of affect, gaining

insight, and enlarging his or her awareness, respectively.

TABLE 3

60

Analysis of Variance

for MAACL Anxiety (A) Scale

 

Source SS df MS F*
Critical Grouping 128.34 1 128.34 0.44
X Non-Critical Grouping 2050.25 7 292.89 '

Session Before
X Critical Session 5.06 2 2.53 0 03
X Session After 1231.78 14 87.98 °
(BCA)
Clients x Therapists 0.09 l 0.09 0 00
269.16 7 38.45 '
Critical Grouping +
Non-Critical Grouping 180.19 2 90.10 0 45
X BCA 2836.97 14 202.64 '
Critical Grouping +
Non-Critical Grouping 86.27 1 86.27 1 00
X Clients + Therapists 606.64 7 86.66 '
BCA X Clients + 108.07 2 54.04 1 28
Therapists 592.43 14 42.32 ‘
Critical Grouping +
Non-Critical Grouping 22.01 2 11.00 0 20
X BCA 785.10 14 56.08 °

X Clients + Therapists

 

*The EF-OS level of significance is achieved by an E ratio

of 5.59 for dfs of 1 and 7, and an F ratio of 3.74 for

dfs of 2 and 14.

TABLE 4

61

Analysis of Variance

for MAACL Depression (D) Scale

 

Source SS df MS F*
Critical Grouping 10.01 1 10.01 0 05
X Non-Critical Grouping 1527.24 7 218.18 '

Session Before
X Critical Session 56.52 2 28.26 0 26
X Session After 1505.65 14 107.55 '
(BCA)
Clients X Therapists 1.76 l 1.76 O 05
261.82 7 37.40 '
Critical Grouping + . .
Non-Critical Grouping 66.89 2 33.45 0 16
X BCA- 4045.11 14 288.94 °
Critical Grouping +
Non-Critical Grouping 0.01 l 0.01 0 00
X Clients + Therapists 425.91 7 60.84 °
BCA X Clients + 69.27 2 34.64 1 75
Therapists 276.90 14 19.78 '
Critical Grouping +
Non-Critical Grouping - 38.40 2 19.20 3 19
X BCA 84.12 14 6.01 ’

X Clients + Therapists

 

*The 25.05 level of significance is achieved by an §_ratio

of 5.59 for dfs of_l and 7, and an E ratio of 3.74 for

dfs of 2 and 14.

62

TABLE 5

Analysis of Variance

for MAACL Hostility (H) Scale

 

Source SS df MS F*
Critical Grouping 10.01 1 10.01 0'17
X Non-Critical Grouping 419.07 7 59.87 °

Session Before
X Critical Session 162.14 2 81.07 1 69
X Session After 670.53 14 47.90 '
(BCA)

Clients X Therapists 31.51 1 31.51 0 60

365.57 7 52.22 '

Critical Grouping + 281.40 2 140.70 1 70
Non-Critical Grouping 1157.27 14 82.66 '
X.BCA

Critical Grouping + 1.76 l 1.76 0 04
Non-Critical Grouping 292.33 7 41.76 '
X Clients + Therapists

BCA X Clients + 32.27 2 16.14 0 50
Therapists 454.40 14 32.46 '

Critical Grouping +
Non-Critical Grouping 46.27 2 23.14 0 56
X BCA 582.41 14 41.60 °

X Clients + Therapists

 

*The ps.05 level of significance is achieved by an E ratio

of 5.59 for dfs of l and 7, and an F ratio of 3.74 for

dfs of 2 and 14.

63

The three TSR items (client form) were:
I feel that I gpt:
49. More ability to feel my feelings, to
know what I really want.
56. More insight into my problems.
59. An awareness of some new things about
myself which I didn't know before.
The three TSR items on the therapist form expressed the
same idea, but from the therapist's perspective. 4

The results of the analyses of variance for these
three TSR items failed to reach p:.05 level of statisti-
cal significance for any item on-any dimension. No
differences were found in this dependent variable between
any session identified as "critical" by the operational
definition and the session preceding it, the session
following it, or the control session. Thus, no statisti-
cally significant results which differentiate "critical
sessions" from other psychotherapy sessions along the
dimensions hypothesized by either the operational or the
theoretical definition can be reported from this study.

A different type of examination of the eight identi-
fied "critical sessions" sought to discover whether there
were any important trends in the affect, content, or
client perceptions in these sessions.

To further examine affect, both clients and therapists

were instructed to circle the one feeling that the client

64

felt most during the session. These responses are pre-
sented in Table 6. Only one dyad (S2) perceived the
client's salient affect in the same way. All of the
other responses were completely different from each other
within dyads, and with only one exception, between dyads.
vConsequently, no trends were discovered regarding salient
affects expressed by clients during "critical sessions."
To examine content further, clients and therapists
were instructed to check which of a list of subjects con-
tained in the TSR (items 2 - 21) was talked about most
during the session. The therapists' and Clients' percep-
tions of which subject was discussed most are presented
in Table 7. There was greater agreement between clients
and therapists in this area than for expressed affect,
with three dyads (84, SS, and S6) in agreement (38%). Two
other dyads had client and therapist responses which were
similar in nature (81 and 83), although not identical.
Some trends were reflected in the subjects talked about
most during a "critical session": (1) Past or present
'relationships with members of the client's immediate
family (7 responses, 43%), and (2) Hopes or fears about
the future (4 responses, 27%). There was so much varia-
bility in total responses, however, that no definitive
statement can be made concerning the content of "critical

sessions."

65

TABLE 6

The One Feeling Felt Most by the Client During

His or Her "Critical Session"

 

 

Therapists Clients
Subject MAACL MAACL
Dyad Item Number Affect ; Item Number Affect
$1 3 AffectiOnate 100 Satisfied
52 122 Unhappy 122 Unhappy
S3 8 Alive 118 Thoughtful
S4 , 4 Afraid 26 Cool
SS 12 Angry 62 Hostile
S6 132 Young 105 Steady
S7 21 Cheerful 31 Daring

SB 8 Alive 66 Inspired

66

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67

To further examine client perceptions, clients and
therapists were also asked to check which of a list of
TSR responses (items 42 - 60) described what the client
got most out of the session. These responses are presented
in Table 8. Here, too, there was no agreement between
clients and their therapists. Some trends did emerge,
however, concerning what the client got most out of a
"critical session": (1) Greater understanding or insight
(7 responses, 43%), and (2) Relief from tension and unpleas-
ant feelings (2 responses, 13%). Although it appears that
obtaining insight may have been a common factor in many of
these "critical sessions," the expression of affect, a close
relationship between client and therapist, therapist support
and empathy for the client, and the client's feeling hope
were also listed as primary benefits from these sessions.
Despite their variety, all the responses in Table 8 relate
to the theoretical definition of a "critical session."

These trends may lend some support to the hypotheses of
this study.

The clients were given the opportunity to relate in
their own words what they felt was most helpful to them
during the session in response to CSQ item 13. The res-
ponses for the eight "critical sessions" are presented in
Table 9. Seven of the client responses (88%) were con-

cerned with the gaining of insight. One involved the

68

TABLE 8
What the Client Got Most Out of

His or Her "Critical Session"

 

 

Subject TSR

Dyad Person Item No. Response

51 Therapist 55 Getting my client to take a
more active role and re-
sponsibility for progress
in therapy

51 Client 51 More of a person-to-person
relationship with my therapist

82 Therapist 46 Helping my client understand
the reasons behind his/her
reactions

82 Client 53 A more realistic evaluation
of my thoughts and feelings

S3 Therapist 56 Helping my client get more
insight into his/her problem

83 Client 46 More understanding of the
reasons behind my behavior
and feelings

S4 Therapist 56 Helping my client get more
insight into his/her problems

S4 Client 43 Hope: a feeling that things
can work out for me

85 Therapist 48 Encouraging attempts to change
and try new ways of behavior

SS Client 56 More insight into my problems

S6 Therapist 49 Moving'my client closer to
experiencing emergent feelings

56 Client 45 Relief from tension and un-
pleasant feelings

S7 Therapist 47 Supporting my client's self-

esteem and confidence

69

Table 8 (cont'd.)

 

Subject

Dyad Person

S7 Client

$8 Therapist
58 Client

TSR
Item No.

 

46

45

Response

More understanding of the
reasons behind my behavior
and feelings

Sharing empathically in what
my client was experiencing

Relief from tension and un-
pleasant feelings

70

TABLE 9

Clients' Responses to CSQ Item 13:

"What was most helpful to you in today's session?"

Subject
Dyad
$1

82

S3

S4

85

56

S7

88

for His or Her "Critical Session"

Client Response

 

My therapist helped me to objectively analyze
some things.

The therapist suggesting a different way to
look at how I think and feel.

I understood some new things about myself.

Being verbally torn apart. It showed me that
I truly did know what I was talking about.

My therapist was able to tell me that my de-
cisions were made on external pressure not
internal direction. My therapist was able
to spot what was causing many of my feelings
and was able to be very supportive.

Exploring my feelings and attempt to gain some
insight in them. Helping me look at the con-
flictual nature of my child-adult perspective.

Certain things are suddenly becoming clear to
me.

A chance to express a lot of good feelings - it
was sort of a "show-off" session for me.

71

expression of good feelings. In view of what these clients
chose to emphasize, these results may lend support to the
theoretical definition for a "critical session," for which
obtaining insight is a core element.

Although there were no satisfactory significant
results supporting the specific hypotheses in this study,
there were other results which indicated trends in the
direction predicted by the theoretical definition for a
"critical session." In addition, these results may indi-

cate some support for the general hypothesis of this study.

DISCUSSION

The present study was undertaken (l) to explore
the possibility that a useful operational definition of
psychotherapy sessions variously described as "turning
points," "important," or "critical sessions" could be
constructed, and (2) to apply this operational defini-
tion in real psychotherapy settings. In addition,
supporting hypotheses regarding the nature of several
changes in the mind of the client thought to take place
in "critical sessions" were developed and an experiment
was designed to identify these changes and to demon-
strate that these particular changes differentiate
"critical sessions" from all other individual therapy
sessions. r

This section contains a discussion of:

l) the inferences that can be derived from the

results of the experiment,

2) methodological considerations affecting the

results, and

3) the implications of the present study for future

research.

72

73

Findipgs

 

The results produced by this study suggest that a
meaningful operational definition fOr a "critical session"
can be applied to psychotherapeutic situations. The
results of a survey of researChers and therapists pointed
to variables that these respOndents believed were involved
in a "critical session" or a "turning point" in the
prosess of psychotherapy.

These variables were scaled and used to construct
the "Critical Session" Questionnaire. From the CSQ,
"critical sessions" in eight of ten different client-
therapist dyads meeting for ten sessions were identified.
These "critical sessions" were found to have CSQ scores
vsignificantly different (p<.0005) than the scores from the
total group of sessions Sfudied.

The success of the CSQ in determining whether valid
"critical sessions" do exist can only be considered tenta-
tive by virtue of the results of this investigation. Nor
is it clear how seriously these results undermine the
value of this concept. For example, the CSQ is an instru-
ment involving only one item per variable. It may not tap
necessary variables with adequate representativeness or
reliability. Furthermore, there are no established norms
for the items listed, and it is not clear to what extent
there may have been within individual variation in the

self-reports. Finally, the number of clients, therapists,

74

and sessions in which the CSQ was used was relatively
small. This, of course, limits the power and extent of
the conclusions reached from its results. The CSQ is

at this stage, therefore, a rather gross instrument, and
the results obtained must be viewed accordingly. The
results do suggest that further refinement of the CSQ
would be fruitful, however. These refinements of the
CSQ will be described below with the recommendations for
future research.

The first two objectives of the present study, the
construction of an operational definition for a "critical
session" and the identification of "critical sessions"
using this Operational definition can be said to have been
fulfilled. Identifying these "critical sessions," however,
does not mean that any single, most outstanding and most
important session for the course of the entire therapy
has been pinpointed. The theoretical definition requires
that a "critical session" in the form of a single "turn-
ing point" or most crucial session for the whole therapeu-
tic relationship be identified. But in view of the
necessary restrictions involved in this study, e.g., the
collection of questionnaire data from clients and thera-
pists, a limit of ten sessions was imposed. Such
restrictions may obscure the nature of "critical sessions"
as established by the theoretical definition. As an

example, if the entire course of any particular therapy

75

had been examined, another session might have shown a
far higher median on the CSQ than the one identified in
the present study. These other "critical sessions"
might have yielded different results upon analysis. The
failure of this study to support hypotheses 1 and 2
indicates that a valid means for identifying a single
most important, or "turning point" session for a therapy
is yet to be demonstrated.

The eight sessions identified as "critical" appear
to be related to some interesting responses. The clients,
according to their CSQ responses, felt each to have been
a "good" session in terms of their goals for therapy:
confronting one of their main problems directly; express-
ing feelings concerning one of their main problems; learn-
ing important and useful things about themselves; and
improving their view of themselves, the course of their
therapy, their personal environment, and their therapists.
By their own reports, clients indicated that more positive
elements had occurred in these eight sessions than in
almost all of the other sessions. Seemingly, some impor-
tant steps or progress had been made in the eight sessions.
In fact, there were more than eight sessions in which
these CSQ scores were elevated. The two dyads which were
not considered to have had a "critical session" were
excluded because they had more than one session with a

high median, and the operational definition required that

76

only one be present. Such occurrences could imply that
more than one "critical session" occurs over the length.
of therapy or that a number of such sessions occur.

In theoretical terms, a number of confrontations of
the main problems, with accompanying emotional release
and close contact with the therapists, may be necessary
if the client is to be motivated to continue therapy.
Experiencing these sessions may be necessary in order
that the client can continue facing main problems and
the distress of experienced anxiety in the other sessions.
It seems logical that clients would only desire to con-
tinue treatment if they felt that some significant amount
of progress was being made toward understanding and solv-
ing their main problems. In this light, it may be far
more productive for clients to have a series of moderately
impactful "important" sessions during the course of therapy
than a single, highly impactful "critical session."
Frequent sessions shOwing what looks like "progress" may
do more than a single session to sustain the client
through periods of difficulty and anxiety, to enable the
client to absorb and utilize new understandings, establish
a higher level of self-esteem, to help the client to
practice expressing troublesome affect, and to promote the
sense of hope for a better future. A series of "turning
points" may also lead the client to establish a pattern

of success in tackling the difficult work of understanding

77

and working through the conflicts, whereas a single
"critical session" may, in fact, only serve to heighten
expectations which would not be fulfilled.

An alternate theoretical speculation is that these
"high progress" sessions may merely be necessary stepping-
stones to a very powerful "critical session" in which
the main conflicts are confronted even more dramatically.
Perhaps a great deal of groundwork is required for the
major "critical session" or "turning point" to occur, and
while the "groundwork" sessions may at the time be viewed
by the client as "high progress" sessions, they may be
only rated afterwards as less important than the "critical
session." In other words, the perspective of the client
at the end of the course of therapy may be very different
and perhaps more useful in rating these "high progress"
sessions than before the client has experienced a truly
"critical session."

Respondents to the PSQ who rejected the notion of
a single "critical session" as defined in this study had
set forth the above notions on the existence of: (1) a
number of "high progress" sessions which are similar to
"critical sessions" in their process and which lay the
groundwork for the occurrence of "critical sessions," and
(2) temporal effects on a client's perspective. While

it appears that this study has produced information

78

regarding a particular view of "critical sessions," any
match between these operationally defined "critical
sessions" and the ones described by the theoretical
definition remains to be demonstrated.

The findings from the two dependent measures, the
MAACL and the TSR, failed to demonstrate either that the
theorized changes predicted as a result of a "critical
session" actually happened, or that the identified
"critical sessions" differed in qualitative ways from
other sessions. This lack of significant results may be
related to the choice of instruments used to measure the
dependent variables.

The MAACL, however, was selected because of its past,
apparently reliable, and valid application in assessing
changes in affect, a crucial component of a "critical
session." But the obtained results may indicate that the
MAACL may not be well suited to detecting the types of
affect and affect changes that occur prior to, during,
and following a "critical session." The MAACL does not
sufficiently identify qualitative changes in affect and
degree of affect experienced, which may be more important
changes occurring in "critical sessions" than the changes
in discrete affects that this instrument does measure. In
addition, a number of written and verbal comments by both
therapists and clients indicated that this check list did

not allow them to express the feelings they had experienced

79

adequately. An inspection of the data also appeared to
indicate that some subjects did not fill out the check
list reliably. Occasionally, client responses for a
particular session contradicted each other on similar
or corresponding items in the three instruments.

The TSR was selected for use in this study because
of its ability to distinguish between various factors
that are occurring in the process of therapy, its pre-
vious use in examining "good" sessions, and its tested
reliability and validity. Its exhaustive treatment of
the therapy session, and therefore its length, however,
seems to have been its major drawback here. It appears
that some subjects experienced testing fatigue and used
little care in filling out the long TSR. There were
several complaints about its length, and a few clients
dropped out of the study because of this after completing
only a few questionnaires. This testing fatigue may have
contributed to lowering the reliability of the TSR
results. In addition, the quality and experience of
change in the client or in the client-therapist relation-
ship may not have been accurately estimated or accounted
for by this type of instrument.

Consequently, qualitative differences between
"critical sessions" and other sessions may exist, al-

though they were not detected through the use of these

80

measurements. The fact that the CSQ seems useful for
identifying "critical sessions" in a number of therapy
dyads offers some evidence for the existence of "turning
points" in the process of therapy, especially as they
reflect both judgments of clients and experienced
therapists. These judgments may be verifiable if
appropriate techniques are used. For example, factor
analysis of the data from a large number of client-
therapist pairs over a longer period of therapy than
studied here might be more useful and more effective

in detecting "critical session" occurrence patterns.

Methodological Considerations

This study contains certain basic assumptions upon
which its research methodology is built. Although these
basic assumptions are widely employed, a number of re-
viewers of the psychotherapy research literature have
questioned the validity of applying some of these assump-
tions.

For example, the assumption that "critical sessions"
can be found in a wide variety of client-therapist pairs
was employed here because of this researcher's theoretical
conviction and because he deemed it necessary to explore
this essentially uninvestigated area. No previous re-
search has helped establish guidelines in the search for

"critical sessions."

81

Nevertheless, worth consideration is the fact that
a number of psychotherapy researchers (Sanford, 1953;
Kiesler, 1966; Paul, 1967; Marsden, 1971; and Bergin
and Strupp, 1972) state that instead of trying to find
general principles applicable to all of psychotherapy,
research should concentrate on trying to determine
particular sets of therapeutic factors and behaviors
that are appropriate for particular types of clients
and therapists within particular contexts. They argue
that the styles of psychotherapy commonly practiced and
the types of clients coming for help are too varied to
have a certain fixed set of therapeutic variables general-
izable to all therapy situations. This reasoning may
explain some of the results obtained in this study, since
the results reflect that a number of "critical sessions"
were identified but that no generalizable conditions over
all the dyads could be found. However, the objections
to this assumption are at present still open to debate
and remain unsupported by empirical efforts.

Another assumption in this study, that examining only
part of the psychotherapy process can yield valid infor-
mation, is challenged by Kiesler (1966). He states that
investigations must exhaust the full domain of variables
operative in the therapy interaction in order to be com-
prehensive enough to explain the psychotherapy process

adequately. Although the present study used two lengthy

82

questionnaires to generate data for the dependent
variables, they fell short of covering the full range
of processes in therapy. Though it is a desirable
method of researchm administering to clients and thera-
pists the necessary comprehensive set of instruments
required by this method would have been impossible with
the resources available to this researcher. Further-
more, it may be that Kiesler's view of how research
should be conducted, while possibly valid, is highly
impractical, considering both the difficulty in enlisting
therapist participation and the testing fatigue that was
experienced when only three instruments were used.

A third assumption, that client and therapist self-
report was an adequate means of identifying and examining
"critical sessions" may have been the most telling cause
for the lack of significant results. While clients and
therapists may be able to walk out of a session feeling
that the session had been "good," they may not be able
to analyze and report what facets of the interaction led
to this feeling, especially within the highly structured
confines of questionnaires like the MAACL and the TSR.
Also, as time passes, clients and therapists may change
their minds; sessions that seemed "ordinary" or "not
particularly significant" immediately after the session
may be looked back upon after the passage of time as

having been "important," "significant," or "critical" in

83

the perspective gained following it. Conversations with
experienced therapists yielded the opinion that this
attitude shift was not an uncommon experience. It may
be that sessions that were considered by clients at

the time to have been "bad" or "irrelevant to their
problems" may have indeed been in accord with the theor-
etical definition of a "critical session" but were not
identifiable by the operations used because of the
reliance on the client's feelings for the measurements.
A "critical session" might be considered by a client to
have been a "bad" session if the client, following the
session, experienced a great deal of emotional turmoil
as a result of having one of his or her main conflicts
confronted and dealt with in the sessiOn. The client
may then respond to this emotional turmoil following the
session rather than to a more objective appraisal of

the session's importance.

The study attempted to control for some of this
variance in client response by including therapists'
perceptions of Clients' responses on the MAACL. However,
the results failed to demonstrate any significant differ-
ences between therapists' and Clients' responses on the
dependent variables. While these results show some measure
of agreement between clients and therapists on the per-

ceptions of the Clients' affects and behaviors in the

84

session, they are questionable indicators of the validity
of therapist reports. Because of their involvement in
the therapy process, therapists may be no more Objective
in their assessment of a session's "importance" or
"critical" nature than clients. Without other sorts

of data against which to check these views, ascertain-
ing the degree of objectivity in a client's or thera-
pists view of a particular session is extremely diffi-
cult.

Perhaps the most significant contributing factor
to invalidating a client's self-report is the nature of
his or her problems. For example, can a client whose
main difficulties include an inability to perceive or
accept positive feelings of others towards him or her
be able to report accurately on the warmth and caring
expressed by the therapist during and following the
therapist's confrontation of his or her conflicts in
the theorized "critical session"? Can the client who
is experiencing the pain associated with the conflict
confronted by the therapist feel that the session has
been "good" or "important" or a "turning point"? Then
again, the client may not have had the affective exper-
ience, education, experiences with psychotherapy, or
developed conceptualizing abilities necessary to recog-

nize and report on some of the esoteric factors involved

85

in a "critical session." An indication that this pre-
mise may be accurate lies in the nature of responses

by clients concerning the most helpful and least helpful
circumstances of a particular session, and what enabled
them to talk about the problems and feelings they dis-
cussed in that session (questions 13, 14, and 10 respect-
ively on the CSQ). For the most part, client responses
to these unscaled free response items were vague; they
were either very general or very specific, unconnected

to the question, unsophisticated, or simply "nothing" or
"I don't know." Such answers tend to cast doubts upon
both the reliability and validity of the scaled items

in the TSR which more specifically ask the same questions,
but require only a minimum of thought plus little under-
standing or conceptualizing to circle a number. Clients
may not be able to verbalize their "inner experiences"
adequately in the language presented to them by current
research techniques. It is a possibility that the "inner
experience" can neither be detected nor collected by
client self-report, although this is a matter that has
been much debated in the past and still remains unresolved.
Regardless of the eventual answer to this question, the
present study tends to indicate that in examining "criti-
cal sessions" other means of data collection must be
employed in addition to self-report to obtain accurate

and objective information on these sessions.

86

Moreover, the problems that appear to be inherent
in the methodology of the present study may also apply
to most of the quantitative research methods currently
employed in psychotherapy research. An unresolved
difficulty in empirical investigations in psychotherapy
is that it is extremely hard, and perhaps impossible,
to assign numerical ratings to "inner experiences,"
feelings, and perceptions of clients and therapists.

In addition, there is the immense problem of generaliz-
ing the unique and often idosyncratic responses of
individual respondents over a large population of clients

and therapists.

Implications for Future Research
The present investigation failed to provide support
for hypotheses l and 2, but suggests several ways in which
improvements in research design may establish the extent
that the concept of "critical sessions" is useful.
Several different kinds of studies might shed
light on the nature of the concept. One such study,
for example, would redesign and improve upon the pres-
ent investigation in the following manner: refine the
CSQ to identify the "best" or "most important" session
for a particular dyad, as opposed to possible "very
good" or "important" sessions. A new survey that listed

a greater number of variables would be administered to

87

a far greater number of researchers and therapists. A
new CSQ could then be constructed using several items
for each variable with the reliability and validity of
the items to be tested in a pilot study.

In order to determine one "superior" session
rather than a session that is "good" or "impOrtant"
relative to only a few other sessions, it would be
necessary to administer the CSQ to clients and thera-
pists after every session over the entire course of
therapy. Clients whose therapy lasts for a short, mod-
erate or long duration could be divided into separate
groups in order to determine if there is a difference
over the time dimension in distinguishing "superior"
sessions. The median of the scores on the CSQ for the
"critical session" must be clearly and significantly
outstanding in relation to the medians for the other
sessions. Further, a minimum positive median should be
established as a result of the CSQ pilot study to be the
minimum level for "criticalness" (e.g., a median of +3.0
on a scale of 0.0 to 4.0), with a certain high percent-
age of the items also required to be above a'particular
,minimum level.

At the termination of therapy the clients and ther-
apists could be given a form and/or interview asking
them to identify the session which had been most impor-

tant to the progress of therapy. This form or the

88

interview could then ask them to describe what happened
and what made it important. This retrospective view
would add to the validity of the identified "critical
sessions" because this judgment would be more likely
free of coloration caused by the emotional turmoil in
clients immediately following an individual session.

These terminated clients could also be surveyed to
gather their perceptions of the ingredients found in
an "important" session or "turning point" in therapy.
The nature of this complex design using these instru-
ments and techniques requires a much larger number of
subjects than the number of therapists and clients used
in the present study to provide acceptably valid re-
sults.

Dividing the therapy dyads into groups that are
roughly similar would enable researchers to begin
answering the question of whether "critical sessions"
are phenomena common to most therapy situations or
merely to a few particular types of dyads. Clients
could be categorized by diagnosis after undergoing a
complete psychological evaluation employing a full
battery of standard tests administered by psychologists
unconnected with the research. Therapists could be
typed according to their style of therapy, including
both their reported theoretical orientation and the

observation of their therapeutic style by trained raters

89

with established inter-rater reliability.

By using appropriate statistical techniques with
a large enough sample, the occurrence of "critical
sessions" by types of clients, types of therapists, and
types of therapeutic situation could be pinpointed.

From the data collected in this manner, a researcher
might extend the scope of the study to include a correla-
tion of the occurrence of "critical sessions" with the
outcome of therapy through the use of outcome measure-
ments. These outcome measurements would need to rely
on "internal" as well as "external" or behavioral
criteria, and should be as comprehensive as possible.

A complete set of outcome measurements should include a
standardized assessment interview, a self-rating check-
list, a behavioral assessment, a self-concept measure,

a thematic story test, a therapist rating scale, the
Personal Orientation Inventory to measure health-oriented
qualities, and a factor-analytic battery such as the
Sixteen Personality Factor Questionnaire. This additional
focus would connect the study of therapy process and
therapy outcome, thus yielding some very useful informa-
tion leading toward a better understanding of psycho-
therapy as a whole.

Several instruments could be employed to collect
the data on dependent variables in this proposed study.

Each instrument should examine one specific aspect of

90

the therapy process in which the instrument has been
shown to have high validity and reliability. All

the information collected would complete a comprehen-
sive picture of the changes which occur in a particular
therapeutic dyad. One criterion for choosing these
Instruments is that they be relatively short to prevent
fatigue in the respondents. The sample should be large
enough to allow for employing factor analysis. This
statistical technique could be of great use in defining
sets of behaviors, feelings, or changes that occur
uniquely in the process of a "critical session."

For non-quantitative investigation, information
collected about "critical sessions" would be thematic
and experiential instead of quantitative. This method
of research, however, should still follow an empirical
procedure in order to assure the validity of its results.
First, a team of two or more judges would be selected.
Judges would be experienced and well-qualified thera-
pists who are generally considered to be perceptive,
sensitive, and good therapists by their colleagues and
clients alike. These judges would be employed to view
videotapes and listen to audiotapes of many therapy
sessions and to make judgments on what they see and hear.

Next, many therapists across the nation would be
solicited to send in tapes of sessions that they and

their clients agree are "superior," "good" or "important,"

91

and tapes of sessions deemed to be "inferior", "bad"
or "unimportant." The judges would then listen to these
tapes and by their professional judgments determine what
themes, actions, expressions, therapeutic situations,
emotions, key interactions, and inner experiences or
other occurrences or lack of occurrences differentiate
sessions in terms of "good" from "bad," "superior" from
"inferior," and "important" from "unimportant." A great
number of sessions would be needed so that these judges
could come to agreement on the types of processes which
support these distinctions. Through these reviews these
judges can develop the experience, skill, and knowledge
necessary both to formulate an operational definition for
a "critical session" and identify these sessions when they
occur. The third step for these judges would be to
listen to the tapes of the sessions examined by quantita-
tive methods and identify "critical sessions" in those
dyads to validate their findings against the quantitative
approach.

Working independently, a second set of judges
chosen in the same way as the first would at this point
continue the investigation. They would not be informed
of the nature of the study or the concept of "critical
sessions." They would be trained in the use of several
psychotherapy rating systems until they had a high degree

of inter-rater reliability on each system. They would

92

then listen to all of the tapes for all of the client-
therapist pairs from the quantitative study, with the
tapes being presented to them in a random order. They
would then apply both the rating systems and their pro-
fessional judgments along the dimensions identified by
the first set of judges to each session. In addition,
a member of this second set of judges would interview
the clients and therapists after every fifth session in
order to determine their perceptions on what had trans-
pired, what had resulted, and what changes had taken
place over the previous five sessions. A short inter-
view after every fifth session would be often enough to
capture the needed information before it is forgotten
while not being so frequent that it would interrupt
the process of therapy. After therapy is terminated, a
judge would interview each of them to obtain as much
information as possible on how they viewed the progress
of therapy and what was most important in enabling them
to reach the outcome they achieved. By the point of
termination, of course, much would be forgotten about
what had occurred during the therapy, but what was
remembered and why it was remembered would provide
important clues to what had been of significance in the
therapy.

The data obtained from the rating systems would be

analyzed by statistical methods, but the thematic and

93

judgmental information would be compiled and discussed in
a reportorial manner.. Since the same client-therapist
pairs would be used throughout all aspects of the study
the quantitative results could be compared with both the
judges' data and the judges' assessments to provide a
broad, comprehensive examination of the concept of "criti-
cal sessions." Such a study combining the dual foci of
quantitative and qualitative research would go far in
determining the existence of, the identification of, the
occurrence of, and the therapeutic impact of "critical
sessions." Further research studies could be well guided
by the findings produced by this type of comprehensive
and exploratory initial investigation. Otherwise, re-
searchers may expend much effort examining small segments
of this area and not arrive at an accurate total picture
of the nature of "critical sessions."

The present study indicated some guideposts for
further investigation, enabling future researchers to
have a greater possibility of providing some definitive
and valid data in a largely unexplored area of psycho-

therapy research.

SUMMARY AND CONCLUSIONS

This research sought to study the nature of "criti-
cal sessions" in individual adult psychotherapy. Theo-
retically, a "critical session" was conceptualized as a
session in the process of therapy in which the therapist
confronted or interpreted some key set of feelings or
behaviors to which the client is receptive, and which
results in the client having felt some significant emo-
tional impact, having achieved a sense of mutual closeness
with the therapist, having had some major cognitive
reorganization, having achieved some_important insight
in a way that is useful, and having shifted some of his
or her distorted perceptions of the therapist more toward
reality.

The concept of a "critical session" had to be oper-
ationally defined. This was accomplished for this study
by a survey of experienced psychotherapists. Data from
a preliminary set of interviews with experienced thera-
pists was used to construct the Psychotherapist Survey
Questionnaire (PSQ). The PSQ was sent to 62 experienced
therapists and researchers to collect data on their views
on whether "critical sessions" exist, and, if they be-
lieved so, what variables might be present in such sessions.

Forty-six respondents agreed with the concept, while six

94

95

did not, and ten did not respond. The 46 positive
respondents, who had a mean experience level of 14.4
years, identified three variables (PSQ items VI, IX, and
X) which they considered "extremely important" to a
"critical session". A t-test performed on the PSQ data
showed the responses for these three items to be signif-
icantly different from the total group of PSQ responses
(p<.0005).

_ These three PSQ items were converted into seven
items on the "Critical Session" Questionnaire (CSQ), an
instrument developed for this study with the aim of
identifying "critical sessions". Two additional items
concerning the importance of the session and the client's
goals for therapy were also included in the CSQ. The
operational definition for a "critical session" for this
study was the highest median for a client's ratings for
a session on these nine CSQ items, with at least seven
of these items needing to be rated at equal to or greater
than + 2.

It was hypothesized that (l) a change in the client's
report of his or her affect from the session immediately
preceding a "critical session" to the session immediately
following a "critical session" as measured by the Multiple
Affect Adjective Check List would occur (p:.05), and (2)
that a change in the therapist's report of the client's
experienced affect over these same sessions measured by

the same instrument would occur (p:.05).

96

Ten adult clients in individual therapy and their
therapists were administered the CSQ, the Multiple Affect
Adjective Check List (MAACL), and the Therapy Session
Report (TSR) after each of ten consecutive sessions.
Therapists chose both the clients and the starting points
in the therapy process for this research. Five dyads
started participating in this study before the twentieth
session and five began at some point after the twentieth
session.

Eight of the ten dyads were found to have had an
operationally defined "critical session". A t-test per-
formed on the CSQ results demonstrated that these eight
"critical sessions" were significantly different in their
CSQ client ratings than the total group of sessions
studied (p<.0005). A three-way analysis of variance was
'performed—on the MAACL scores for the eight "critical
sessions", the sessions immediately preceding and follow-
ing them, and on three randomly selected consecutive
sessions from these same dyads which served as controls.
The results of the analysis of variance (1) failed to
support either of the hypotheses, and (2) failed to demon-
strate that the identified "critical sessions" were
different than other sessions in their client MAACL
scores. Three TSR items pertaining to variables in the
theoretical definition of a "critical session" were then

subjected to a similar three-way analysis of variance.

97

This statistical analysis also failed to differentiate
"critical sessions" from other sessions. Finally, items
involving which client affect was felt most, what was
talked about most, and what was most beneficial to the
client during the eight "critical sessions" were examined
in a non-statistical manner. Two trends were discovered:
(1) Past or present relationships with members of the
client's immediate family was the most frequently reported
content matter (43%), and (2) Attaining greater understand-
fng or insight was most frequently reported to be what the
client got most out of the session (43%).

Although the hypotheses were not supported, "critical
sessions" were identified in eight therapy dyads and some
trends concerning the nature of "critical sessions" were
uncovered. Some of the methodology utilized in this
study may have contributed to the lack of significant
results, e.g., the small number of subjects, the types of
instruments used and their length, and the examination of
only ten sessions rather than the entire course of a therapy.
Enough information was collected, however, to suggest the
value of further research in the area of "critiCal sessions"

using more refined methodology.

APPENDICES

APPENDIX A

APPENDIX A

The Psychotherapist Survey Questionnaire

Dear

I am a graduate student in clinical psychology working on
my doctoral dissertation, and I would like to request your
assistance in filling out a very short questionnaire for

my research. This questionnaire should take no more than

5 minutes of your time. Your reply will be extremely help-
ful to me in resolving the main problem I have had in
progressing with my study.

My research concerns an analysis of particular sessions
in individual psychotherapy. Many therapists tend to
describe some sessions with a client as "more important"
or "better" than others. Carrying this idea to its ex-
treme, I have decided to examine what transpires in
sessions rated as "the most important" in the course of
psychotherapy) how the processes occurring in these
sessions differ from those of other sessions, and what
changes take place within the client, the therapist, and
their relationship. One additional question I hope to
begin to shed some light on is whether these sessions
are "critical" to the therapy process, or in other words,
whether they are "turning points" in the course of psycho-
therapy.

In order to formulate an operational definition of this
type of session, I have gathered information from ther-
apists in my area as to what they see occurring in such
"critical sessions" and I have formed a composite list

of all the assorted variables that these therapists have
perceived as being present in those sessions (with no one
therapist seeing all of these variables listed as being
present). As an experienced psychotherapist and psycho-
therapy researcher it would be of great aid to me if you
could rate these variables according to the rating scales
provided. If you agree that "critical sessions" as I
have briefly defined them in Part 1 of the questionnaire
do occur with at least some Clients, please fill out all
of Part 1 only. If you do not agree that "critical
sessions" as defined in Part 1 occur at all, please ignore
Part 1 and fill out Part 2 only. Fill out either Part 1
pp Part 2, but not both.

APPENDIX A (continued)

I would greatly appreciate your assistance in aiding me
with my research by filling out this short questionnaire.
Please return this questionnaire to me as soon as possible.
For your convenience I have enclosed a stamped, self-
addressed return envelope. Feel free to make any comments
on either my project or my questionnaire. If you wish I
will send you the results of this questionnaire once the
data is analyzed.

Thank you for your time and your cooperation.

Sincerely,

Neil E. Rand

APPENDIX A (continued)

Psychotherapist Surveypguestionnaire

Years of psychotherapy experience Degree

PART 1

In the process of individual psychotherapy there are
sometimes particular sessions which are critical to the
successful outcome of the therapy. In the cases where
they occur these key sessions can be called "turning
points," for what is involved is a subtle or overt change
in the process of therapy which leads to the achievement
of the goals of therapy (whatever these goals may be for
that particular client-therapist pair). Some crucial
changes take place in the sessions where these turning
points occur which provide the necessary tools or atmos-
phere for that client-therapist pair to reach a success-
ful outcome; tools or atmosphere which for whatever reason
were not available for full use of the client-therapist
pair prior to the occurrence of the turning point. Oper-
ating under the assumption that such turning points or
critical sessions do exist at least in some cases, use
your experience as a therapist, your conceptual knowledge
of individual psychotherapy, and your theoretical base to
rate the list of variables in the following manner:

Positive Ratings: This variable occurs in "critical"
sessions and is of importance to what transpires during
that session.

+1 = Slightly important
+5 = Moderately important
+10 = Extremely important

Neutral (0) Rating: This variable occurs in "critical"
sessions but is neither important nor unimportant to what
transpires during that session.

 

Negative Ratings: This variable occurs in "critical"
sessions but is not important to what transpires during
that session.

 

-l = Slightly unimportant
-5 = Moderately unimportant
-10 = Extremely unimportant

X Rating: This variable does not occur in "critical"
sessrons.

APPENDIX A (continued)

Part 1 (continued)

Variables

 

Circle the appropriate rating for each item.

I. Greater total affect is expressed by the client
than previously.

X -10 -9 -8 -7 -6 -5 —4 -3 -2 -1 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

II. Greater anxiety is experienced by the client than
previously.

X -10 -9 —8 -7 -6 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

III. The session was felt by the client to be important
in terms of progress toward his or her goals in
psychotherapy.

X -10 -9 -8 -7 -6 -5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

IV. The session was felt by the therapist to be impor-
tant in terms of his or her goals for the client in
psychotherapy.

X -10 -9 -8 -7 -6 -5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

V. The therapist expresses more affect than previously.

X -10 -9 -8 -7 -6 -5 -4 -3 —2 -1 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

VI. Some conflict that the client has been dealing with
in a less direct or less affect-laden manner gets
confronted directly.

x -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

VII. Some part of the client's distortions about the
therapist are removed; the therapist is perceived
by the client more as he or she really is.

X -10 -9 -8 -7 -6 -5 -4 ~3 -2 -1 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

APPENDIX A (continued)

Part 1 (continued)

VIII. The client experiences the therapist as more caring.

X -10 -9 -8 -7 -6 -5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

IX. Some material that the client was previously unaware
of is brought into the client's awareness in a way
that is useful to him or her.

X -10 -9 -8 -7 -6 -5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

X. Some cognitive reordering occurs in the client so
that he perceives the therapy situation, himself,
the therapeutic relationship, or his world view in
a different way; some important insight is obtained.

X -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

XI. The therapeutic goals of the client and therapist
.are clarified and made more compatible or more
similar.

X -10 -9 -8 -7 -6 -5 -4 -3 -2 —l 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

(Optional) XII. Other:

 

X -10 -9 -8 -7 -6 -5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5 +6
+7 +8 +9 +10

 

I wish to have the results of this questionnaire
sent to me.

 

 

 

APPENDIX A (continued)

PART 2

If you do not agree with the definition of "critical
sessions" as stated in Part 1, please briefly describe
what you do see occurring in "critical" or "very impor-
tant" sessions, or why you feel that such sessions do

not occur .

APPENDIX B

APPENDIX B

The Client Background Questionnaire

INSTRUCTIONS: Fill out all of the blanks in Questions
#I’andi#2 and as many of the rest of the questions that
apply for you.

1. Client Identification Code
(Your code is your initials of your first and last
name plus the year you were born. Example: John
Doe who was born in 1948 would have the code --

 

 

 

JD 1948) ~
Birthdate Occupation
Today's Date Sex Marital Status

 

Approximate Annual Income

 

Your Therapist's Name

 

2. Briefly (intone or two sentences) describe the
problem that caused you to seek out psychotherapy.

 

 

 

 

 

3. Have you ever been in any form of psychotherapy
before? CIRCLE ONE: YES NO

 

If YES, What kind? CIRCLE ONE:
INDIVIDUAL GROUP MARITAL FAMILY CHILD

OTHER

 

If YES, For how long?

 

4. How many psychotherapy sessions have you had with your
present therapist not counting today's session?

 

CIRCLE ONE: 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
17 18 19 20 MORE THAN 20

 

APPENDIX C

APPENDIX C
The Therapist Background Questionnaire

INSTRUCTIONS: Please answer all questions.

1. Therapist Identification Code
Today's Date
(Code is formed by the initials of your first and last
names and the year of your birth. Example: John Doe
in 1948 would have the code--JD1948)

 

 

Age Sex Degree

 

Years of Full Time psychotherapy experience (Do not count
experience prior to your degree)

 

2. Which term BEST describes your therapeutic orientation?
CIRCLE ONE:

 

Analytic Bioenergetic Client-Centered Gestalt Jungian
Rankian Rational Emotive Reality Eclectic TA Other

If your answer is ECLECTIC, describe which theories or
elements of theories contribute to your therapeutic style
by CIRCLING WHICHEVER THEORIES YOU USE IN THE LIST BELOW.
Circle a particular theory even if you only use one element
of that theory. THEN--P1ace an "X" ACROSS whichever theory
is most predominant in your therapeutic style (if you have
one that is predominant).

Analytic Bioenergetic Client-Centered Gestalt Jungian

Rankian Rational Emotive Reality TA Other

 

3. ESTIMATE (as best you can) the average number of
sessions that your previous individual adult psycho-
therapy clients have attended.

CIRCLE ONE: 1-5 6-10 11-15 16-20 21-25 26-30 Over 30
4. ESTIMATE the average number of sessions that individual
adult psychotherapy clients you have seen for LONGER

than 12 sessions.

CIRCLE ONE: 1-5 6-10 ll-15 16-20 21-25 26-30 Over 30

 

APPENDIX C (continued)

5. ESTIMATE the number of individual adult psychotherapy
clients you have seen for LONGER than 19 sessions.

CIRCLE ONE: 1-5 6-10 11-15 16-20 21-25 26-30 31-35

 

36-40 41-45 46-50 Over 50

Please return this questionnaire to Neil Rand when completed.

APPENDIX D

APPENDIX D

The "Critical Session"

Questionnaire (Client Form)

YOUR CLIENT IDENTIFICATION CODE: .
(Your client identification code is formed by the initials
of your first and last names and the year in which you were
born. Example: John Doe born in 1948 would have the code--
JD1948)

 

YOUR THERAPIST'S INITIALS:

 

DATE OF SESSION:

 

Check here if this is the FIRST SESSION you have
ever had with THIS THERAPIST.

 

 

 

Check here if this is the FIRST TIME you have
FILLED OUT THIS FORM.

 

 

 

PLEASE RETURN THIS FORM TO THE SECRETARY WHEN YOU HAVE
FINISHED.

BE SURE TO ANSWER ALL OF THE QUESTIONS.

APPENDIX D (continued)

PLEASE ANSWER ALL QUESTIONS.

1. WHAT ARE YOUR FEELINGS ABOUT THE SESSION YOU HAVE
JUST COMPLETED?

Instructions: +5 = The way you would feel if you had
just completed the best possible
session.

 

0 = The way you would feel if you had
just completed an average session.

-5 = The way you would feel if you had
just completed the worst possible
session.

 

Using the above as a guideline, CIRCLE ONE NUMBER on the
scale below that best represents how you felt about the
session you have just completed.

WORST POSSIBLE AVERAGE BEST POSSIBLE
-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

2. HOW WAS THE SESSION FOR YOU IN TERMS OF YOUR GOALS
FOR YOURSELF IN THERAPY?

Instructions: +5 = The best possible session for you in
terms of your goals for yourself.

 

0 = An average session for you in terms
of your goals for yourself in therapy.

-5 = The worst possible session for you in
terms of your goals for yourself.

 

Using the above as a guideline, CIRCLE QNE NUMBER on the
scale below that best represents how the session you have
just completed was for you in terms of your goals for
yourself in therapy.

WORST POSSIBLE AVERAGE BEST POSSIBLE

-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5

' APPENDIX D (continued)

3. DURING THIS SESSION, WERE YOU ABLE TO TALK ABOUT ONE
OF YOUR MAIN PROBLEMS DIRECTLY?

Instructions: +5 = It was as easy as it could possibly
pg for me to talk about one of my
main problems in this session and I
was able to do it.

0 = I was able to talk about one of my
main problems as much as I usually
can in an average session.

 

-5 = It was as difficult as it could pos-
sibly be_for me to talk about one of
my main problems in this session and
I was unable to do it.

DIFFICULT AS IT AS MUCH AS USUAL EASY AS IT
POSSIBLY COULD BE ON THE AVERAGE POSSIBLY COULD BE
-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5

4. DURING THIS SESSION DID YOU EXPRESS ANY EMOTIONAL
FEELINGS CONCERNING ONE OF YOUR MAIN PROBLEMS?

Instructions: +5 = I expressed as many feelings concern-
ing one of my main problems as I could
possibly express.

 

 

0 = I expressed about the same amount of
feelings concerning my main problems
as I usually do in an average session.

 

 

-5 = I expressed as few feelings concerning
one of my main problems as possible.

 

AS FEW AS AS MUCH AS USUAL AS MANY AS
POSSIBLE ON THE AVERAGE POSSIBLE

-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

APPENDIX D (continued)

5. DURING THIS SESSION, DID YOU LEARN ANY NEW AND
IMPORTANT THINGS ABOUT YOURSELF WHICH YOU WILL BE
ABLE TO USE?

I learned as much about myself as I
possibly couId in one therapy session.

Instructions: +5

 

0 = I learned about the same amount about
myself as I usually do in an average
session.

 

-5 = I learned as little about myself as I
possibly could in one therapy seSSIon.

 

AS LITTLE AS MUCH AS USUAL AS MUCH
AS POSSIBLE ON THE AVERAGE AS POSSIBLE

-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5

6. AS A RESULT OF THE SESSION YOU HAVE JUST COMPLETED,
HOW DO YOU VIEW THE FOLLOWING?

 

 

YOURSELF--
I SEE MYSELF AS I SEE MYSELF AS BEING I SEE MYSELF AS
BEING IN THE WORST ABOUT THE SAME BEING IN THE BEST
POSSIBLE WAY AS I USUALLY AM POSSIBLE WAY
-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5

THE COURSE OF YOUR THERAPY--

MY THERAPY SEEMS MY THERAPY SEEMS TO MY THERAPY

TO BE GOING IN THE BE GOING ABOUT THE SEEMS TO BE .

WORST POSSIBLE WAY SAME AS IT USUALLY DOES GOING IN THE
BEST POSSIBLE WAY

 

 

 

-5 -4 -3 ‘ -2 -l 0 +1 +2 +3 +4 +5

APPENDIX D (continued)

AS A RESULT OF THE SESSION YOU HAVE JUST COMPLETED,

HOW

DO YOU VIEW THE FOLLOWING?

YOUR PERSONAL ENVIRONMENT--

I SEE THE
PEOPLE AND THINGS
AROUND ME AS BEING

AS BAD AS THEY
COULD POSSIBLY BE

 

 

-5 -4 -3 -2

YOUR THERAPIST--

I SEE MY THERAPIST
AS BEING AS BAD AS

 

A THERAPIST COULD
POSSIBLY BE

 

 

Instructions for Questions #10 through #14:
FOLLOWING QUESTIONS AS BRIEFLY AS POSSIBLE.

I SEE THE I SEE THE
PEOPLE AND THINGS PEOPLE AND THINGS
AROUND ME AS BEING AROUND ME AS

ABOUT THE SAME BEING AS
AS THEY USUALLY ARE GOOD AS THEY
COULD POSSIBLY BE

 

 

-l 0 +1 +2 +3 +4 +5

I SEE MY THERAPIST AS
BEING ABOUT THE SAME
AS HE/SHE USUALLY IS

I SEE MY THERA-
PIST As BEING
AS GOOD AS A

THERAPIST COULD

POSSIBLY BE

 

 

 

 

-l 0 +1 +2 +3 +4 +5

ANSWER THE
One or two

 

sentences will be enough far each question.

10.

WHAT ENABLED YOU TO TALK ABOUT THE PROBLEMS AND

FEELINGS YOU HAVE DISCUSSED TODAY?

11.

WHAT DID YOU LIKE MOST ABOUT THIS SESSION?

12. WHAT DID YOU LIKE LEAST ABOUT THIS SESSION?

13. WHAT WAS MOST HELPFUL TO YOU IN TODAY'S SESSION?

14. WHAT WAS LEAST HELPFUL TO YOU IN TODAY'S SESSION?

APPENDIX E

APPENDIX E

The "Critical Session"

Questionnaire (Therapist Form)

THERAPIST IDENTIFICATION CODE:

(Your identifying code is formed from the initials of your
first and last names and the year you were born. ”Example:
John Doe born in 1948 would have the code--JDl948)

 

DATE OF SESSION:

 

CLIENT IDENTIFICATION CODE (For the client you saw this
session):

(Your client's identification code is formed the same way
as your code. If you do not know your client's year of
birth, just put his or her initials and the name of your
agency here: )

 

 

ONLY FILL OUT THIS SECTION THE FIRST TIME THAT YOU SEE THIS
CLIENT FOR THIS RESEARCH PROJECT.

 

CHECK HERE IF THIS IS THE FIRST SESSION YOU HAVE
EVER SEEN THIS CLIENT.

 

 

 

IF YOU HAVE SEEN THIS CLIENT BEFORE THIS RESEARCH PROJECT
STARTED, CIRCLE THE SESSION NUMBER THAT TODAY'S SESSION

IS (DO NOT COUNT MISSED OR CANCELLED SESSIONS.) IF THIS
IS NOT YOUR FIRST SESSION WITH THIS CLIENT, YOU SHOULD NOT
HAVE SEEN HIM OR HER FOR TEN SESSIONS OR LESS AND STILL
INCLUDE HIM OR HER IN THIS PROJECT.

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
26 27 28 29 30 31 32 33 34 45 36 37 38 39 4O
41 42 43 44 45 46 47 48 49 50

If more than 50 sessions, write number here:

 

BRIEFLY (IN ONE OR TWO SENTENCES) DESCRIBE THE CLIENT'S
PROBLEM(S) AS YOU SEE IT (OR THEM). PLEASE DO NOT JUST
WRITE A DIAGNOSIS.

APPENDIX E (continued)

PLEASE ANSWER ALL QUESTIONS.

1. WHAT ARE YOUR FEELINGS ABOUT THE SESSION THAT JUST
ENDED?

Instructions: +5 The way you would feel if it had

been the best possible session.

 

0 = The way you would feel if it had been
an average session.

-5 = The way you would feel if it had been
the worst possible session.

 

USING THE ABOVE AS A GUIDELINE, CIRCLE ONE NUMBER ON THE
SCALE BELOW that best represents how you felt about the
session that has just ended.

WORST POSSIBLE AVERAGE BEST POSSIBLE
-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5
2. HOW WAS THIS SESSION IN TERMS OF YOUR CLIENT'S GOALS
FOR HIMSELF/HERSELF IN THERAPY?

Instructions: +5 = The best possible session in terms of
my client's goals.

 

0 = An average session in terms of my
client 5 goals for himself/herself.

-5 = The worst possible session in terms
of my client's goals.

USING THE ABOVE AS A GUIDELINE, CIRCLE QN§_NUMBER ON THE
SCALE BELOW that best represents your ESTIMATE of how this
session was for your client in terms of his/her goals for
himself/herself in therapy.

WORST POSSIBLE AVERAGE BEST POSSIBLE

-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5

APPENDIX E (continued)

3. WAS YOUR CLIENT ABLE TO TALK ABOUT ONE OF HIS/HER
MAIN PROBLEMS IN A DIRECT MANNER?

Instructions: +5 = It was as easy as it could possibly
pg for my client to talk about it in
a direct way.

0 = It was about as much effort as it
usually is for my client and he7she
was able to talk about it somewhat.

-5 = It was as difficult as it could possibly
be for my client to talk about it in a
direct way and he/she could only do it
indirectly, if at all.

DIFFICULT AS IT AS MUCH AS USUAL EASY AS IT
POSSIBLY COULD BE ON THE AVERAGE. POSSIBLY COULD BE
-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5

4. DID YOUR CLIENT EXPRESS ANY AFFECT CONCERNING ONE OF
HIS/HER MAIN PROBLEMS?

Instructions: +5 = My client expressed as much affect as
could possibly be expressed concernifig
one of hi§7her main problems.

0
II

My client expressed about the same
amount of affect concerning one of
his/her main problems as he/she usually
does.

 

-5 = My client expressed as little affect
as could possibly be expressed or none
at all concerning one of his/her main
problems.

 

USING THE ABOVE AS A GUIDELINE, CIRCLE ONE NUMBER ON THE
SCALE BELOW that best represents your ESTIMATE of how much
affect your client expressed in this session concerning
one of his/her main problems.

AS LITTLE A8 AS MUCH AS USUAL . AS MUCH AS
POSSIBLE ON THE AVERAGE POSSIBLE

-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5

APPENDIX E (continued)

5. DID YOUR CLIENT LEARN ANY NEW AND IMPORTANT THINGS
ABOUT HIMSELF/HERSELF WHICH HE/SHE WILL BE ABLE TO
USE?

Instructions: +5 My client learned as many important

things about himself/herself as he/she
possibly_could in a single session.

 

 

0 = My client learned about the same
amount about himself/herself as he/she
usually does in an average session.

 

 

-5 = My client learned as few important
things about himseIf7herself as he/she
possibly could in a single session, or
nothing at all.

 

USING THE ABOVE GUIDELINE, CIRCLE ONE NUMBER ON THE SCALE
BELOW that best represents your ESTIMATE of whether your
client learned any new, important, and useful things about
himself/herself in this session.

AS FEW AS AS MANY AS USUAL AS MANY AS
POSSIBLE ~ ON THE AVERAGE POSSIBLE
-5 -4 -3 -2 -l 0 +1 +2 +3 +4 +5

AS A RESULT OF THE SESSION THAT HAS JUST ENDED, MAKE AN
ESTIMATE OF HOW YOUR CLIENT NOW VIEWS THE FOLLOWING:

6. HIMSELF OR HERSELF--

 

 

SEES SELF AS SEES SELF AS BEING SEES SELF AS
BEING IN THE WORST ABOUT THE SAME BEING IN THE BEST
POSSIBLE WAY AS USUAL POSSIBLE WAY

-5 -4 -3 -2 —l 0 +1 +2 +3 +4 +5

’APPENDIX E (continued)

7. THE COURSE OF HIS/HER THERAPY--

 

 

 

SEES THERAPY SEES THERAPY AS SEES THERAPY
AS GOING IN THE GOING ABOUT THE SAME AS GOING IN THE
"WORST POSSIBLE WAY AS USUAL ' BEST POSSIBLE WAY
-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

8. HIS/HER PERSONAL ENVIRONMENT--

 

 

 

SEES THE PEOPLE. SEES THE PEOPLE SEES THE PEOPLE
AND THINGS AROUND AND THINGS AROUND AND THINGS AROUND

HIM/HER AS BEING HIM/HER AS BEING HIM/HER AS BEING

AS BAD AS THEY ABOUT THE SAME As GOOD AS THEY
COULD POSSIBLY pp AS USUAL COULD POSSIBLY pp
-5 -4 -3 -2 +1 0 +1 +2 +3 +4 +5

9. YOU, THE THERAPIST--

 

SEES YOU AS SEES YOU AS
BEING Ag BAD A§ SEES YOU AS BEING BEING AS GOOD Ag
A THERAPIST COULD ABOUT THE SAME A THERAPIST COULD

POSSIBLY BE AS USUAL POSSIBLY pg

-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

10. BRIEFLY (IN ONE OR TWO SENTENCES) DESCRIBE WHAT WAS
MOST HELPFUL TO YOUR CLIENT IN TODAY'S SESSION:

APPENDIX F

APPENDIX F

The Multiple Affect

Adjective Check List (Client Form)

DIRECTIONS FOR THIS PAGE: Listed below are words which
describe different kinds of moods and feelings. Blacken
in the space beside the words which describe how ygp
felt during the session ygp have just completed. Some
of the words may sound alike, but we want you to check
all the words that describe your feelings in the session.

THEN--CIRCLE the ONE FEELING that you FELT THE MOST
during the session.

1. ACTIVE 34. DEVOTED
2. ADVENTUROUS 35. DISAGREEABLE
3. AFFECTIONATE 36. DISCONTINUED
4. AFRAID 37. DISCOURAGED
5. AGITATED 38. DISGUSTED
6. AGREEABLE 39. DISPLEASED
7. AGGRESSIVE 40. ENERGETIC
8. ALIVE 41. NERAGED
9. ALONE 42. ENTHUSIASTIC
10. AMIABLE 43. FEARFUL
ll. AMUSED 44. FINE
12. ANGRY 45. FIT
l3. ANNOYED 46. FORLORN
14. AWFUL 47. FRANK
15. BASHFUL 48. FREE
16. BITTER 49. FRIENDLY
17. BLUE 50. FRIGHTENED
18. BORED 51. FURIOUS
l9. CALM 52. GAY
20. CAUTIOUS 53. GENTLE
21. CHEERFUL 54. GLAD
22. CLEAN 55. GLOOMY
23. COMPLAINING 56. GOOD
24. CONTENTED 57. GOOD-NATURED
25. CONTRARY 58. GRIM
26. COOL 59. HAPPY
27. COOPERATIVE 60. HEALTHY
28. CRITICAL 61. HOPELESS
29. CROSS 62. HOSTILE
30. CRUEL 63. IMPATIENT
31. DARING 64. INCENSED
32. DESPERATE 65. INDIGNANT
33. DESTROYED 66. INSPIRED

67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
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99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.

APPENDIX F (continued)

INTERESTED
IRRITATED
JEALOUS
JOYFUL
KINDLY
LONELY
LOST
LOVING
LOW

LUCKY
MAD

MEAN
WEEK
MERRY
MILD
MISERABLE
NERVOUS
OBLIGING
OFFENDED
OUTRAGED
PANICKY
PATIENT
PEACEFUL
PLEASED
PLEASANT
POLITE
POWERFUL
QUIET
RECKLESS
REJECTED
ROUGH

SAD

SAFE
SATISFIED
SECURE
SHAKY

SHY
SOOTHED
STEADY
STUBBORN
STORMY
STRONG
SUFFERING
SULLEN
SUNK

SYMPATHETIC

TAME
TENDER
TENSE
TERRIBLE
TERRIFIED

118.
119.
120.
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.

THOUGHTFUL
TIMID
TORMENTED
UNDERSTANDING
UNHAPPY
UNSOCIABLE
UPSET
VEXED
WARM
WHOLE

WILD
WILLFUL
WILTED
WORRYING
YOUNG

PLEASE BE SURE TO CIRCLE THE ONE

FEELING YOU FELT MOST.

APPENDIX G

APPENDIX G

The Multiple Affect Adjective

Check List (Therapist Form)

PUT YOUR IDENTIFICATION CODE HERE:

 

DIRECTIONS FOR THIS PAGE: Listed below are words which
describe different kinds of moods and feelings. Circle
the words which describe how your client felt during 222
session you have just completed. Circle as many of the
feelings as appiy.

 

THEN-~UNDERLINE THE ONE FEELING that your client seemed
to have FELT MOST during the session.

1. ACTIVE 34. DEVOTED
2. ADVENTUROUS 35. DISAGREEABLE
3. AFFECTIONATE 36. DISCONTENTED
4. AFRAID 37. DISCOURAGED
5. AGITATED 38. DISGUSTED
6. AGREEABLE 39. DISPLEASED
7. AGGRESSIVE 40. ENERGETIC
8. ALIVE 41. ENRAGED
9. ALONE 42. ENTHUSIASTIC
10. AMIABLE 43. FEARFUL
11. AMUSED 44. FINE
12. ANGRY 45. FIT
13. ANNOYED 46. FORLORN
l4. AWFUL 47. FRANK
15. BASHFUL 48. FREE
16. BITTER 49. FRIENDLY
17. BLUE 50. FRIGHTENED
18. BORED 51. FURIOUS
19. CALM 52. GAY
20. CAUTIOUS 53. GENTLE
21. CHEERFUL 54. GLAD
22. CLEAN 55. GLOOMY
23. COMPLAINING 56. GOOD
24. CONTENTED 57. GOOD-NATURED
25. CONTRARY 58. GRIM
26. COOL 59. HAPPY
27. COOPERATIVE 60. HEALTHY
28. CRITICAL 61. HOPELESS
29. CROSS 62. HOSTILE
30. CRUEL 63. IMPATIENT
31. DARING 64. INCENSED
32. DESPERATE 65. INDIGNANT
33. DESTROYED 66. INSPIRED

APPENDIX G (continued)

67. INTERESTED 116. TERRIBLE
68. IRRITATED 117. TERRIFIED
69. JEALOUS 118. THOUGHTFUL
70- JOYFUL 119. TIMID

71. KINDLY 120. TORMENTED
72. LONELY 121. UNDERSTANDING
73. LOST 122. UNHAPPY
74. LOVING 123. UNSOCIABLE
75. LOW 124. UPSET

76. LUCKY 125. VEXED

77. MAD 126. WARM

78. MEAN 127. WHOLE

79. MEEK 128. WILD

80. MERRY 129. WILLFUL
81. MILD 130. WILTED

82. MISERABLE 131. WORRYING
83. NERVOUS 132. YOUNG

84- OBLIGING
85. OFFENDED
86. OUTRAGED
87. PANICKY
88. PATIENT
89. PEACEFUL
90. PLEASED
91. PLEASANT

92. POLITE PLEASE BE SURE TO UNDERLINE THE ONE
93. POWERFUL ‘———"
94. QUIET FEELING YOUR CLIENT FELT MOST.

95. RECKLESS
96. REJECTED

97. ROUGH
9' 8 . SAD
99. SAFE

100. SATISFIED
101. SECURE
102. SHAKY
103. SHY

104. SOOTHED
105. STEADY
106. STUBBORN
107. STORMY
108. STRONG
109. SUFFERING
110. SULLEN

111. SUNK
112. SYMPATHETIC

114. TENDER
115. TENSE

APPENDIX H

1.

APPENDIX H

The Therapy Session Report (Client Form)

HOW WELL DO YOU FEEL THAT YOU ARE GETTING ALONG,
EMOTIONALLY AND PSYCHOLOGICALLY, AT THIS TIME?

Circle

1.
2.

one:

Very well; much the way I would like to.
Fairly well; I have my ups and downs.

So-so; manage to keep going with some effort.

Fairly poorly; life gets pretty tough for me
at times.

Quite poorly; can barely manage to deal with
things.

WHAT SUBJECTS DID YOU TALK ABOUT DURING THIS SESSION?
(For each subject, Circle the answer which best

ap

plies.)

DURING THIS SESSION I TALKED ABOUT:

\IO‘U‘DWN
one...

000

10.
11.

12.
13.
14.
15.

16.

NO SOME A LOT

MY MOTHER 0 1 2
MY FATHER 0 1 2
MY BROTHERS OR SISTERS 0 1 2
MY CHILDHOOD 0 1 2
MY ADOLESCENCE 0 1 2
RELIGIOUS FEELINGS, ACTIVITIES
OR EXPERIENCES 0 1 2
WORK, CAREER OR EDUCATION 0 1 2
RELATIONS WITH OTHERS OF THE
SAME SEX 0 l 2
RELATIONS WITH THE OPPOSITE SEX 0 1 2
FINANCIAL RESOURCES OR PROBLEMS
WITH MONEY 0 1 2
FEELINGS ABOUT SPOUSE OR ABOUT
BEING MARRIED 0 l 2
HOUSEHOLD RESPONSIBILITIES OR
ACTIVITIES 0 1 2
FEELINGS ABOUT CHILDREN OR
BEING A PARENT 0 1 2
BODY FUNCTIONS, SYMPTOMS, OR
APPEARANCE 0 1 2
STRANGE OR UNUSUAL IDEAS AND

1 2

EXPERIENCES 0

Q

APPENDIX H (continued)

17. HOPES OR FEARS ABOUT THE FUTURE 0 1 2
18. DREAMS OR FANTASIES 0 1 2
l9. ATTITUDES OR FEELINGS TOWARD MY

THERAPIST 0 l 2
20. THERAPY: FEELINGS AND PROGRESS

AS A PATIENT 0 1 2
21. OTHER: 0 l 2

 

PUT A CHECK (/) IN FRONT OF THE SUBJECT FROM THE ABOVE
LIST THAT YOU TALKED ABOUT MOST DURING THIS SESSION.

BE SURE THAT YOU HAVE ANSWERED EVERY ITEM ON THIS PAGE.

WHAT PROBLEMS OR FEELINGS WERE YOU CONCERNED ABOUT THIS
SESSION? (For each item, circle the answer which best
applies.)

DURING THIS SESSION I WAS CONCERNED ABOUT:
NO SOME A LOT
22. GETTING A CHANCE TO LET GO AND 0 1 2

GET THINGS OFF MY CHEST
23. GETTING RELIEF FROM TENSIONS OR

UNPLEASANT FEELINGS 0 1 2
24. UNDERSTANDING THE REASONS BEHIND

MY FEELINGS AND BEHAVIOR 0 1 2
25. GETTING SOME REASSURANCE 0 1 2
26. HAVING MY THERAPIST RESPOND TO

ME ON A PERSON-TO-PERSON BASIS 0 1 2
27. GETTING BETTER SELF CONTROL 0 1 2
28. GETTING STRAIGHT ON WHICH THINGS

I THINK AND FEEL ARE REAL AND

WHICH ARE MOSTLY IN MY MIND 0 1 2
29. BEING DEPENDENT ON OTHERS 0 l 2
30. MEETING MY OBLIGATIONS AND

RESPONSIBILITIES 0 1 2
31. BEING ASSERTIVE OR COMPETITIVE 0 l 2
32. LIVING UP TO MY CONSCIENCE:

SHAMEFUL OR GUILTY FEELINGS « 0 1 2
33. BEING LONELY OR ISOLATED 0 1 2
34. SEXUAL FEELINGS AND EXPERIENCES O 1 2
35. EXPRESSING OR EXPOSING MYSELF

TO OTHERS 0 1 2
36. LOVING: BEING ABLE TO GIVE OF

MYSELF 0 1 2
37. ANGRY FEELINGS OR BEHAVIOR 0 1 2
38. WHO I AM AND WHAT I WANT 0 1 2
39. FEARFUL OR PANICKY EXPERIENCES 0 l 2

APPENDIX H (continued)

40., MEANING LITTLE OR NOTHING TO
OTHERS: BEING WORTHLESS OR
UNLOVABLE

41. OTHER:

 

PLEASE BE SURE THAT YOU HAVE ANSWERED EVERY ITEM.

\

WHAT DO YOU FEEL THAT YOU GOT OUT OF THIS SESSION?

(For each item, circle the answer which best applies.)

I FEEL THAT I GOT:

42. ACCEPTANCE OF WHO I AM BY MY
THERAPIST

43. HOPE: A FEELING THAT THINGS
CAN WORK OUT FOR ME

44. HELP IN TALKING ABOUT WHAT WAS
REALLY TROUBLING ME

45. RELIEF FROM TENSIONS AND UN-
PLEASANT FEELINGS

46. MORE UNDERSTANDING OF THE REASONS
BEHIND MY BEHAVIOR AND FEELINGS

47. REASSURANCE AND ENCOURAGEMENT
ABOUT HOW I'M DOING: SUPPORT

48. CONFIDENCE TO TRY TO DO THINGS
DIFFERENTLY

49. MORE ABILITY TO FEEL MY FEELINGS,
TO KNOW WHAT I REALLY WANT

50. IDEAS FOR BETTER WAYS OF DEALING
WITH PEOPLE AND PROBLEMS

51. MORE OF A PERSON-TO-PERSON RELA-
TIONSHIP WITH MY THERAPIST

52. BETTER SELF CONTROL OVER MY
MOODS AND ACTIONS

53. A MORE REALISTIC EVALUATION OF
MY THOUGHTS AND FEELINGS

54. EMPATHY FOR WHAT I WAS EXPER-
'IENCING

55. CONFIDENCE TO TAKE GREATER
RESPONSIBILITY FOR MY PROGRESS
IN THERAPY

56. MORE INSIGHT INTO MY PROBLEMS

57. A DIFFERENT VIEW OF MY THERAPY
OR MY RELATIONSHIP WITH MY
THERAPIST

58. A DIFFERENT VIEW OF MYSELF

NO

000

SOME

H P‘ +4 id H

H F‘ +4 id H h» be re

F‘H

A LOT

NN

APPENDIX H (continued)

59. AN AWARENESS OF SOME NEW THINGS
ABOUT MYSELF WHICH I DIDN'T
KNOW BEFORE .

60. SOME CLARIFICATION AS TO THE WAY
PEOPLE REALLY ARE 0 1 2
NOTHING IN PARTICULAR: I FEEL
THE SAME AS I DID BEFORE THE
SESSION 0 1 2
OTHER: 0 1 2

PUT A CHECK (/) IN FRONT OF THE ITEM FROM THE ABOVE LIST
THAT BEST DESCRIBES WHAT YOU GOT MOST OUT OF THIS SESSION.

BE SURE THAT YOU HAVE ANSWERED EVERY ITEM

FOR EACH ITEM, CIRCLE THE ANSWER WHICH BEST APPLIES;

DURING THIS SESSION, HOW MUCH: . Slightly
or Not Pretty Very
At All Some Much Much

 

61. DID YOUR THERAPIST TALK? 0 1 2 3
62. WAS YOUR THERAPIST ATTENTIVE

TO WHAT YOU WERE TRYING TO

GET ACROSS? 0 1 2 3
63. DID YOUR THERAPIST TEND TO ACCEPT

OR AGREE WITH YOUR IDEAS AND POINT

OF VIEW? 0 l 2 3
64. WAS YOUR THERAPIST NEGATIVE OR
CRITICAL TOWARD YOU? 0 l 2 3

65. DID YOUR THERAPIST TAKE INITIATIVE

IN BRINGING UP THINGS TO TALK

ABOUT? 0 1 2 3
66. DID YOUR THERAPIST TRY TO GET

YOU TO CHANGE YOUR POINT OF VIEW

OR WAY OF DOING THINGS? 0 1 2 3
67. WAS YOUR THERAPIST FRIENDLY AND

WARM TOWARDS YOU? 0 1 2 3
68. DID YOUR THERAPIST SHOW FEELING? 0 1 2 3
69. DID YOUR THERAPIST CONFRONT YOU

ON WHAT YOU WERE SAYING OR DOING? 0 1 2 3

70. DID YOUR THERAPIST MAKE INTER-
PRETATIONS ON YOUR THOUGHTS,

DREAMS, FEELINGS OR BEHAVIOR? 0 1 2 3
71. WHAT IMPACT DID YOUR THERAPIST
HAVE UPON YOU? 0 l 2 3

72. DID YOU ACHIEVE A SENSE OF
MUTUAL CLOSENESS WITH YOUR
THERAPIST? 0 1 2 3

73.

74.

75.

APPENDIX H (continued)

DID YOUR THERAPIST REVEAL
SPONTANEOUS IMPRESSIONS OR

REACTIONS? 0 l 2
WAS YOUR THERAPIST IN RAPPORT
WITH YOUR FEELINGS? 0 1 2
DID YOUR THERAPIST UNDERSTAND
WHAT YOU SAID AND DID? 0 1 2

PLEASE BE SURE THAT YOU HAVE ANSWERED EVERY ITEM.

THANK YOU FOR YOUR HELP.

APPENDIX I

APPENDIX I

The Therapy Session Report (Therapist Form)
1. HOW WELL DO YOU FEEL THAT THE CLIENT SEEMS TO BE GETTING

ALONG, EMOTIONALLY AND PSYCHOLOGICALLY, AT THIS TIME?
CIRCLE ONE:

1. Very well; much the way he/she would like to.
2. Quite well; no important complaints.
3. 50-30; manages to keep going with some effort.

4. Fairly poorly; life gets pretty tough for him/
her at times.

5. Quite poorly; can barely manage to deal with
things.

WHAT SUBJECTS DID YOUR CLIENT TALK ABOUT DURING THIS
SESSION? (For each subject, circle the answer which
best applies.)

 

DURING THIS SESSION HE/SHE NO SOME A LOT
TALKED ABOUT:
2. HIS/HER MOTHER 0 1 2
3. HIS/HER FATHER 0 l 2
4. HIS/HER BROTHERS OR SISTERS 0 l 2
5. HIS/HER CHILDHOOD 0 l 2
6. HIS/HER ADOLESCENCE 0 1 2
7. RELIGIOUS FEELINGS, ACTIVITIES
OR EXPERIENCE 0 1 2
8. WORK, CAREER, OR EDUCATION 0 1 2
9. RELATIONS WITH OTHERS OF THE
SAME SEX 0 1 2
10. RELATIONS WITH THE OPPOSITE SEX 0 1 2
11. FINANCIAL RESOURCES OR PROBLEMS
WITH MONEY 0 1 2
12. FEELINGS ABOUT SPOUSE OR ABOUT
BEING MARRIED 0 1 2
13. HOUSEHOLD RESPONSIBILITIES OR
ACTIVITIES O 1 2
l4. FEELINGS ABOUT CHILDREN OR BEING
A PARENT 0 1 2
15. BODY FUNCTIONS, SYMPTOMS OR
APPEARANCE 0 1 2
16. STRANGE OR UNUSUAL IDEAS AND
EXPERIENCES 0 1 2
17. HOPES OR FEARS ABOUT THE FUTURE 0 1 2

APPENDIX I (continued)

18. DREAMS OR FANTASIES 0 1 2
l9. ATTITUDES OR FEELINGS TOWARD

HIS/HER THERAPIST 0 1 2
20. THERAPY: FEELINGS AND PROGRESS

AS A PATIENT 0 1 2
21. OTHER: ' 0 1 2

 

PUT A CHECK (/) IN FRONT OF THE SUBJECT FROM THE ABOVE
LIST THAT YOUR CLIENT TALKED ABOUT MOST IN THE SESSION.

BE SURE THAT YOU HAVE ANSWERED EVERY ITEM

WHAT PROBLEMS OR FEELINGS WAS YOUR CLIENT CONCERNED ABOUT
THIS SESSION? (For each item, circle the NUMBER answer
which best applies. Circle a LETTER answer ONLY if you
circle a "l" or a "2" for that item. If you circle a "0"
do NOT circle a letter answer for that item.)

Letter answers: A Relatively Affectless and
Uninvolved '
Moderately Affective and Involved

Strongly Affective and Involved

B
C

DURING THE SESSION HE/SHE

 

WAS CONCERNED ABOUT: NO SOME A LOT .g p g
22. GETTING A CHANCE TO LET o 1 2 A B C

GO AND GET THINGS OFF HIS/

HER CHEST
23. GETTING RELIEF FROM TENSIONS

OR UNPLEASANT FEELINGS o 1 2 A B c
24. UNDERSTANDING THE REASONS

BEHIND HIS/HER FEELINGS

AND BEHAVIOR o 1 2 A B C
25. GETTING SOME REASSURANCE 0 1 2 A B C

26. HAVING HIS/HER THERAPIST

RESPOND TO HIM/HER ON A

PERSON-TO-PERSON BASIS O l 2 A B C
27. GETTING BETTER SELF

CONTROL 0 1 2 A B C

28.

29.
30.

31.
32.
33.
34.
35.
36.

37.
38.

39.

40.

41.

APPENDIX I (continued)

GETTING STRAIGHT ON WHICH

THINGS HE/SHE THINKS ARE REAL

AND WHICH ARE MOSTLY IN HIS/

HER MIND
BEING DEPENDENT ON OTHERS

MEETING HIS/HER OBLIGATIONS

AND RESPONSIBILITIES
BEING ASSERTIVE OR COM-
PETITIVE

LIVING UP TO HIS/HER
CONSCIENCE: SHAMEFUL
OR GUILTY FEELINGS

BEING LONELY OR ISOLATED
SEXUAL FEELINGS AND
EXPERIENCES

EXPRESSING OR EXPOSING
HIM/HERSELF TO OTHERS
LOVING: BEING ABLE TO
GIVE OF HIM/HERSELF
ANGRY FEELINGS OR BEHAVIOR
WHO HE/SHE IS AND WHAT
HE/SHE WANTS

FEARFUL OR PANICKY
EXPERIENCES

MEANING LITTLE OR NOTHING
TO OTHERS: BEING WORTH-
LESS OR UNLOVABLE

OTHER:

 

0
0
0
0

CO

H H‘ FJH

(a H HHH H F‘ PJH

? 3’ {V3, ID > 3’> lb > 3’>

>

PLEASE BE SURE THAT YOU HAVE ANSWERED EVERY ITEM

03 (U CD01
0 0 00

O O 00 O O 00

U1 ('11 mm I'D (I! mu:

IN WHAT DIRECTION WERE YOU WORKING WITH YOUR CLIENT THIS
SESSION? (For each item, circle the answer which best
applies.)

I WAS WORKING TOWARD:

 

42.

43.

44.

HELPING MY CLIENT FEEL ACCEPTED

IN OUR RELATIONSHIP

GETTING A BETTER UNDERSTANDING
OF MY CLIENT, OF WHAT WAS REALLY

GOING ON

HELPING MY CLIENT TALK ABOUT HIS/

HER FEELINGS AND CONCERNS

NO

SOME

A LOT

APPENDIX I (continued)

45. HELPING MY CLIENT GET RELIEF FROM

TENSIONS OR UNHAPPY FEELINGS 0 l 2
46. .HELPING MY CLIENT UNDERSTAND THE

REASONS BEHIND HIS/HER REACTIONS 0
47. SUPPORTING MY CLIENT'S SELF-

ESTEEM AND CONFIDENCE 0
48. ENCOURAGING ATTEMPTS TO CHANGE

AND TRY NEW WAYS OF BEHAVIOR 0
49. MOVING MY CLIENT CLOSER TO

EXPERIENCING EMERGENT FEELINGS 0
50. HELPING MY CLIENT LEARN NEW WAYS

FOR DEALING WITH SELF AND OTHERS 0

0

H
N

51. ESTABLISHING A GENUINE PERSON-TO-

PERSON RELATIONSHIP WITH MY CLIENT
_52. HELPING MY CLIENT GET BETTER SELF

CONTROL OVER FEELINGS AND IMPULSES .0
53. HELPING MY CLIENT REALISTICALLY

EVALUATE REACTIONS AND FEELINGS 0
54. SHARING EMPATHICALLY IN WHAT MY

CLIENT WAS EXPERIENCING 0
55. GETTING MY CLIENT TO TAKE A MORE

ACTIVE ROLE AND RESPONSIBILITY

FOR PROGRESS IN THERAPY 0
56. HELPING MY CLIENT'GET MORE INSIGHT

INTO HIS/HER PROBLEMS .0 1 2
57. HELPING MY CLIENT GET A DIFFERENT

PERCEPTION OF THE THERAPY SITUA-

TION AND THERAPEUTIC RELATIONSHIP 0 1 2
58. HELPING MY CLIENT GET A DIFFERENT

VIEW OF HIMSELF/HERSELF 0 1 2
59. HELPING MY CLIENT GET AN AWARENESS

OF SOME NEW THINGS ABOUT HIMSELF/

HERSELF THAT HE/SHE WAS PREVIOUSLY

UNAWARE OF 0 1 2
60. HELPING MY CLIENT GET CLARIFICATION

ON THE WAY PEOPLE REALLY ARE 0 l 2

H F4 +4 H F‘ be we H
N

H
N

PUT A CHECK (/) IN FRONT OF THE ITEM FROM THE ABOVE LIST
THAT BEST DESCRIBES WHAT YOUR CLIENT SEEMED TO HAVE GOTTEN
MOST OUT OF THIS SESSION.

APPENDIX I (continued)

Slightly
or Not Pretty Very
DURING THIS SESSION, HOW MUCH: At All Some Much Much

61. DID YOU TALK? 0 1 2 3
62. WERE YOU ATTENTIVE TO WHAT

YOUR CLIENT WAS TRYING TO

GET ACROSS? o 1 2 3
63. DID YOU TEND TO AGREE WITH

OR ACCEPT YOUR CLIENT'S

IDEAS OR SUGGESTIONS? o 1 2 3
64. WERE YOU CRITICAL OR DIS-

APPROVING TOWARDS YOUR

CLIENT? 0 1 2 3
65. DID YOU TAKE INITIATIVE IN

DEFINING THE ISSUES THAT

WERE TALKED ABOUT? 0 . l 2 3
66. DID YOU TRY TO CHANGE YOUR

CLIENT'S POINT OF VIEW OR

WAY OF DOING THINGS? 0 1 2 3
67. WERE YOU WARM AND FRIENDLY

TOWARDS YOUR CLIENT? 0 1 2 3
68. DID YOU EXPRESS FEELING? 0 1 2 3

69. DID YOU CONFRONT YOUR CLIENT
ON WHAT HE/SHE WAS SAYING OR .
DOING? 0 1 2 3
70. DID YOU MAKE INTERPRETATIONS
ON YOUR CLIENT'S THOUGHTS,

DREAMS, FEELINGS OR BEHAVIOR? O 1 2 3
71. WHAT IMPACT DID YOU HAVE ON
YOUR CLIENT? 0 1 2 3

72. DID YOU ACHIEVE A SENSE OF

MUTUAL CLOSENESS WITH YOUR

CLIENT? 0 1 2 3
73. DID YOU REVEAL YOUR SPON-

TANEOUS IMPRESSIONS OR

REACTIONS TO YOUR CLIENT? 0 1 2 3
74. WERE YOU IN RAPPORT WITH
YOUR CLIENT'S FEELINGS? 0 1 2 3

75. DID YOU FEEL YOU UNDERSTOOD
OF WHAT YOUR CLIENT SAID .
AND DID? _ o 1 2 3

PLEASE BE SURE THAT YOU HAVE ANSWERED EVERY ITEM

THANK YOU FOR YOUR HELP

APPENDIX J

APPENDIX J

Instructions to Therapists

The selection of clients to participate in this research
project will be performed by the therapists.

GUIDELINES FOR SELECTION OF CLIENTS

Choose ONE or TWO clients who meet the following criteria:

1)
2)

3)

4)

5)

At least 18 years old

NOT psychotic, schizophrenic, psychopathic, or
sociopathic--this is to be determined by your
judgment.

If you decide to have TWO clients in this'project,
TRY to select one male and one female IF YOU CAN--
EHis is preferable but not a necessity. Whether .
you choose to have one or two clients in the pro-
ject, don't bother with selecting clients according
to any demographic variables (i.e. age, race,
religion, etc.).

Are in INDIVIDUAL therapy with you--no multiple
or co-therapy.

Choose clients who by your judgment will stay in
therapy for 12 sessions from the starting point
of the project--this is difficult to predict, so
make the best guess that you can when selecting
a client.

You may choose clients who EITHER

Are about to start their FIRST SESSION with you

9.11

Are about to start their ELEVENTH QR GREATER SESSION
with you.

From this starting point questionnaires are to be completed
immediately after each of the next TEN consecutive sessions
(or as soon after each of these sessions as is possible).
Missed or cancelled sessions are not to be counted toward
the total of ten sessions.

APPENDIX K

APPENDIX K

Consent for Participating

in Research Form

A research project is being undertaken by Neil E.
Rand of the Michigan State University Department of
Psychology in order to better understand the processes
involved in therapy and what happens in certain sessions
at particular points in time that is helpful to people
coming in for therapy. To do this, both clients and
therapists will complete a form at the end of each
therapy session. The information obtained will be
statistically analyzed. This research should not
interfere with the regular therapy procedures that
people normally experience.

I, (YOUR NAME) ,
understand the nature of the research to be undertaken
and I agree that information obtained during the course
of my therapy sessions may be used for research purposes.
This permission covers the use of any test results, ther-
apist reports, and my own reports. This permission is
given with the understanding that all information collected
is confidential, that this information will be treated in
a professional manner, and that adequate safeguards will
be taken to insure anonymity.

 

I also understand that my therapist will not see any
information collected about me in this research project
without additional written permission.

Signed

 

Address

 

 

Telephone Number

 

Date

 

APPENDIX L

APPENDIX L

Results Obtained From the Therapist and

Client Background Questionnaires

Mean Therapist Age = 38

Number of male therapists = 8

Number of female therapists = 2
Therapists with doctoral degrees = 7

Therapists with medical (psychiatry) degrees 1

Therapists with masters degrees in social work = 2

Mean years of full-time psychotherapy experience = 8.4

Therapeutic orientation:
Analytic = 2
Eclectic = 7
Transactional Analysis = l

Predominant therapeutic style for those therapists who
listed their therapeutic orientation as "eclectic":
Analytic = 4
Client-centered = 2
Existential = l

Therapists' estimates of the average number of sessions
that their previous individual adult psychotherapy clients
have attended:
6 - 10 sessions
11 - 15 sessions
16 - 20 sessions
21 - 25 sessions
26 - 30 sessions
over 30 sessions

II II II II II II
NHHHHA

APPENDIX L (continued)

Therapists' estimates of the average number of sessions
that individual adult psychotherapy clients attend in
that therapist's agency:
6 - 10 sessions
11 - 15 sessions
16 - 20 sessions
21 - 25 sessions
over 30 sessions

II II II II II
HHwa

Therapists' estimates of the number of individual adult
psychotherapy clients they have seen for longer than
ten sessions:

6 - 10 clients = 1
ll - 15 clients = 2
16 - 20 clients = l
21 - 25 clients = 1
31 - 35 clients = 1
36 - 40 clients = 1
over 50 clients = 3

Mean age of clients = 29.7 years

Clients' occupations:
Student = 5
Housewife = 2
Factory worker = 1
College instructor = 1
None reported = 1

Number of male clients = 3
Number of female clients = 7

Marital status of clients:
Married = 4
Single = 4
Divorced = 2

Mean annual income of clients: $9100

Mix of clients and therapists by sex:
Male client with male therapist = 3
Male client with female therapist =
Female client with male therapist =
Female client with female therapist

IlUlO

APPENDIX L (continued)

Number of clients previously in therapy = 6
Type of previous therapy:
Individual adult = 5
Individual child = 1

Reported length of previous therapy:
1 client reported 5 or 6 sessions
2 clients reported 2 or 3 months
3 clients reported 5 or 6 months

Clients' descriptions of the problems that caused them to
seek out psychotherapy:

"I became intensely anxious over my 3 1/2 year old
child's fear of 'growing up', especially in regard
to great resistance to toilet training, and there-
fore sought advice from an 'expert'."

"Problems with husband and children. I suppose
caused by low self-image."

"I was in a deep depression about what I was doing
with my life."

"I was extremely anxious while on campus. I had
negative feelings about school work, and found they
were interfering with my accomplishments. I often
was depressed because I thought I wasn't doing as
well in school as I could."

"Relational problems with family, poor self-identity."

"The reason I decided to seek out professional help
was that I always felt insecure in a relatiOnship
when there was no need to feel that way. I also felt
that I couldn't cope or deal with major or minor
problems in a relationship (male-female)."

"Whenever I'm around people, I get upset; shake,
perspire, panic!"

"I was extremely depressed (for 10 years) and had
ideas that my friends were plotting against me."

"At this point in my life, I felt that I did not have
control over my life--what I did and what happened to/
at me. I did not like this."

BIBLIOGRAPHY

BIBLIOGRAPHY

Auerbach, A. and Luborsky, L. Accuracy of judgments of
psychotherapy and the nature of the "good hour". In
Shlien, J. (ed.), Reseggch ingpsychotherapy, Vol. 3.
Wash., D.C.: American Psychological Association, 1968,
155-168.

Bergin, A. E. and Strupp, H.H. Changing frontiers in the
science of psychotherapy. Chicago: Aldine, 1972.

Carkhuff, R. R. and Berenson, B. G. Beyond counseling

and therapy. New York: Holt, Rinehart and Winston,
I967.

 

Frankl, V. E. Commentary in Standal, S. W. and Corsini,
R. J. (eds.), Critical incidents in psychotherapy.
Englewood Cliffs, N.J.: Prentice-Hall, 1959, 10.

Greenson, R. The tgghnique and practice of psychoanalysis,
Vol. 1. N.Y.: International UniVersities Press, 1967.

Kell, B. L. and Mueller, W. J. Impact and Change: A
study of counseling relationships. N.Y.: Appleton-
Century-Crofts, 1966.

 

 

Kiesler, D. J. Some myths of psychotherapy research and
the search for a paradigm. Psychological Bulletin,
1966, §§(2), 110—136.

Marsden, G. Content-analysis studies of psychotherapy:
1954 through 1968. In Bergin, A. and Garfield, S.
(eds.), Handbook of_psychotherapy and behavior change.
N.Y.: John Wiley, 1971.

May, R. Existence. N.Y.: Simon and Schuster, 1958.

Meltzoff, J. and Kornreich, M. Research in psychotherapy.
N.Y.: Atherton, 1970.

Mintz, J.; Auerbach, A.; Luborsky, L.; and Johnson, M.
Patient's, therapist's and observer's views of psycho-
therapy: A "Rashomon" experience or a reasonable
consensus? British Journal of Medical Psychology,
1973, £§(1), 83-89.

BIBLIOGRAPHY (cont'd.)

Mueller, W. Personal communication. Michigan State
University, 1974.

Orlinsky, D. E. and Howard, K. I. The good therapy
hour: Experimental correlates of patients' and
therapists' evaluations of therapy sessions. ‘
Archives of General Psychiatry, 1967, ii, 621-632.

Paul, G. L. Strategy of outcome research in psychotherapy.
Journal of Consulting Psychology, 1967, 31, 109-118.

Rogers, C. R. On becoming a person. Boston: Houghton
Mifflin, 1961.

Sanford, N. Clinical methods: Psychotherapy. Annual
Review of Psychology, 1953, 4, 317-342.

Snyder, W. U. Commentary in Standal, S. W. and Corsini,
R. J. (eds.), Critical incidents in psychotherapy.
Englewood Cliffs, N.J.: Prentice-Hall, 1959, 20.

Sorokin, P. A. Commentary in Standal, S. W. and Corsini,
R. J. (eds.). Critical incidents in psychotherapy.
Englewood Cliffs, N.J.: Prentice-Hall, 1959, 22.

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