Only for Grade

Working With the Process Dimension in Relational Therapies: Guidelines for Clinical Training

Edward Teyber and Faith McClure Teyber California State University

This article offers guidelines for training relationally oriented therapists. We highlight core concepts that are widely used across relationally oriented therapies. We focus on the process dimension and the therapeutic relationship, and illustrate how process comments are the moderator variable that makes each of the core concepts more effective. Guidelines are provided for clinical instructors to help their trainees use these challenging, but potent, interventions that bring intensity to the therapeutic relationship and help provide the corrective emotional experience.

Keywords: interpersonal process, process dimension, relational therapies, clinical training

We love this work, and feel privileged to spend our time helping clients and training therapists. Combined, we have been practicing relationally oriented therapies for over 75 years. Long ago, we both entered graduate school with interests in child therapy— sustaining core sensibilities that are evident in the attachment- informed, developmental, and familial perspectives that still guide us with clients of all ages. Over the years, we have sought super- vision, training, and our own personal therapy in differing inter- personal/relational approaches, and have been enriched by each of these traditions. Like many, we see more similarities than differ- ences across relational approaches, and we are heartened by the pioneering work of Stephen Mitchell (1988) and many other theorists who seek more coherence and collaboration across dif- ferent interpersonal/relational approaches (Goldfried, 2006; Nor- cross, 2002). Thus, the aim of this special issue is to foster a more universal relational orientation and shared identity among clini- cians—and we are honored to participate in this effort toward self-definition.

Our approach links core treatment concepts, widely used across relationally oriented therapies: the Working Alliance; Rupture and Repair; Attuned Responsiveness and Empathic Understanding; the Internalization of important relationships as Mental Representa- tions; and a Collaborative and Egalitarian stance toward the client. We also believe that important aspects of clients’ presenting prob- lems will emerge in the therapeutic relationship. In particular, we believe that clients change in treatment by finding a corrective emotional experience (CEE) in their relationship with the therapist. Here they experientially find— often for the first time— both a “safe haven” (empathic responsiveness to their vulnerability and distress) and a “secure base” (active support for their individuation and differentiation) in their relationship with the therapist. In this

way, they “earn security” and function more flexibly and effec- tively with greater reflective capacity (Teyber & McClure, 2011).

Clinical training is complex and multifaceted, and we focus here on what we believe to be the most far-reaching but challenging topic: How relationally oriented therapists can use “process com- ments” to make each of these relational treatment constructs more effective. We believe the focus on process— on the here-and-now interaction between the therapist and client—is not just one of many possible interventions; it is an indispensable common de- nominator of effective therapists and links together relationally minded clinicians (Yalom & Leszcz, 2005). Process comments are forthright, but collaborative, bids from therapists to explore what is most salient about what is occurring between them right now. However, here is the bind we have long struggled with as clinical instructors. We believe process comments are the moderator vari- able that makes these relational constructs work. They bring im- mediacy and intensity to the therapeutic relationship and give us a way to enter the client’s distress and engage directly with their core concerns. However, they are unfamiliar and often intimidat- ing to new therapists, and challenging both for instructors to teach and for trainees to adopt. Thus, the purpose of this article is to highlight common difficulties that process-oriented interventions evoke for many trainees and provide guidelines for instructors to help with trainees’ anxiety about working within the relationship and with such immediacy. Trainees cannot adopt these process- oriented interventions about “you-and-me” by just reading articles or discussing them in class—they need instructors to role play or demonstrate them before they can begin to say, “Oh, that’s what you mean” or, better yet, “Yeah, I can do that.” Without these behavioral role models that help trainees “see” these challenging interactions, too many promising trainees will turn away because of the ambiguities and feelings of inadequacy that are commonly evoked by using immediacy interventions. Anxious trainees may turn toward more prescriptive therapies that focus solely on the presenting problem. These manualized approaches are reassuring because they provide more structure and direction— but offer less because they do not conceptualize or intervene with clients’ prob- lems in a relational context. Instructors aim to empower student therapists to take the personal risks evoked by breaking familial

This article was published Online First April 28, 2014. Edward Teyber and Faith McClure Teyber, Department of Psychology,

California State University. Correspondence concerning this article should be addressed to Edward

Teyber, Department of Psychology, 5500 University Parkway, California State University, San Bernardino, CA 92407. E-mail: eteyber@csusb.edu

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Psychotherapy © 2014 American Psychological Association 2014, Vol. 51, No. 3, 334 –341 0033-3204/14/$12.00 DOI: 10.1037/a0036579

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and social rules. Here they invite clients to explore together what may be going on in their relationship that may inform what is also going wrong in their personal lives. Thus, our goal is to help instructors overcome trainees’ anxiety about utilizing themselves and become more adept at working “in the moment” with clients.

The CEE: The Core Relational Factor for Change

We believe that a common distinguishing factor across rela- tional therapies is an appreciation of the developmental, famil- ial, and cultural context for understanding clients and guiding treatment plans. There is a shared sensibility that clients’ sig- nificant and enduring problems developed in caregiving rela- tionships, are being amplified in current relationships, and can be resolved within therapeutic relationships. In this way, a cardinal concept across relational therapies is the CEE (Cas- tonguay & Hill, 2012). To effect change, relational therapists are trying to disconfirm or expand Internal Working Models (IWMs) and avoid replaying in treatment what has gone wrong in other important relationships— especially along the process dimension or way in which the therapist and client are inter- acting together. Although such reenactments are inevitable at times, we do not want them to characterize the ongoing inter- action with the therapist. Instead, we can make process com- ments to identify or highlight maladaptive interactions, and to change them by making them overt and talking them through with the client. Providing this experience of change—that some relationships can now be different and not go down familiar, expected but unwanted lines—is a core component of change in relational approaches (Teyber & McClure, 2011).

Further, empathic attunement (relatedness) coupled with support for differentiation (separateness) also allows the therapist to pro- vide clients with a new and corrective response to the problematic patterns than they have experienced with important others in the past—and come to expect in current relationships. Change occurs as these new ways of relating with the therapist expands clients’ cognitive schemas, alters their beliefs about themselves and ex- pectations of others, and allows them to increase their interper- sonal range. We find that, across varying approaches to relation- ally oriented treatments, this remains a consistent model of change. However, this model requires the therapist to be able to talk about “you and me” and “what is going on between us,” and to collab- oratively discern whether the therapist– client interaction is being slotted into problematic schemas, or if it disconfirms familiar templates and provides new relational options.

Teaching Trainees to Use Process Comments and Intervene in the Moment

We look now at a group of closely related interventions that therapists can use to work in the moment and use the therapeutic relationship as the primary vehicle to facilitate change and provide a CEE. Therapists within diverse relational approaches have writ- ten about these interventions—and termed them metacommunica- tions, immediacy interventions, and so forth. However, we prefer to follow Irvin Yalom working in a group psychotherapy modality, and Virginia Satir and other early family systems theorists, who call these interventions “process comments.” We will see below that there are many types of process comments, but they have been

used similarly and have a common purpose across varying rela- tional approaches. Each type of process comment requires the therapist’s “Use-of-Self” to intervene in the here and now and talk with clients about what may be going on between them in their current interaction. For example, Therapist (T): “I just broached a sensitive topic, and I’m wondering how you are feeling about me doing that?” Our aim is to help relationally oriented trainees learn how to use process comments to: Help clients enter treatment with a lower drop-out rate; Establish and sustain a stronger working alliance; Address resistance and schema distortions; Clarify the client’s problems with more specificity and better discern a treat- ment focus; and Restore ruptures. Process comments link these widely appreciated relational interventions and make each of them more potent. They allow therapists to engage clients in far more meaningful ways and, when used compassionately, bring about more genuine and collaborative relationships. We also believe that, across treatment approaches, the “capacity to engage” is a defining therapist variable that differentiates more and less effective ther- apists within each treatment brand—and process comments help create meaning and enhance therapist– client engagement (Teyber & McClure, 2000).

Process comments make the interaction between the therapist and client overt and put the relationship “on the table” as a topic for discussion. There is a distinction between the overtly spoken content of what is discussed and the process dimension of how the therapist and client interact. The single biggest challenge for instructors is to help trainees contain their anxiety and work through how process comments often conflict with their famil- ial rules and cultural prescriptions. Instructors wish to invite discussion about how unacceptable it was for most trainees to break the social rules and talk with family members about “you and me” and their current interaction. Instructors should antic- ipate that, initially, most trainees will find it blunt or disre- spectful to use “you and me” language. Instructors help by doing two things. First, instructors want to discourage trainees from using these types of interactions in their personal lives, where they often will not be well-received. Second, instructors need to be aware that many trainees will inaccurately slot their discussions about these process interventions into their own familiar, but problematic, developmental experience of being painfully confronted, put on the spot, or intruded upon. Thus, instructors want to clarify that these process interventions should never be confrontational, intrusive, or judgmental. In- stead, they are merely observations, tentatively suggested, about what may be occurring between the therapist and client. With this Use-of-Self, the therapist is judiciously using her own experience of the client to wonder aloud about what might be going on between them right now, and offers this as an invita- tion for further dialogue and mutual sharing of perceptions. Researchers find that process comments offered tentatively (“It sounds like . . .”; “I’m wondering if . . .”; “Maybe . . .”) are more effective than direct challenges (“I think you . . .”; Miller, Benefield, & Tonigan, 1993). Let’s illustrate how therapists can use process comments with “skillful tentativeness,” as an invi- tation to explore their relationship: T: As you’re talking about him and what went on between you two, I’m wondering if you might be saying something about our relationship as well? Does that ever come up between us, too? Client (C): Well, yeah, you’re the therapist—you’re always in control of what goes on

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in here.1 In these ways, process comments commonly reveal significant unspoken conflict between the therapist and client.

Activating Stalled Relationships and Altering Maladaptive Patterns

Above, we see that process comments also uncover covert issues—significant misunderstandings or faulty expectations that are going on in the therapeutic relationship without the therapist’s awareness. Process comments make overt unspoken problems that will cause ruptures and reenactments in the therapeutic relation- ship, and give relational trainees the opportunity to sort them through and resolve them (Safran, Muran, & Proskurov, 2009). Process comments are also a useful option for trainees when they feel the interaction has become repetitive or “stuck,” or treatment has lost its focus: T: I’ve gotten lost a bit. I’m not quite sure where we are going with this right now; maybe I’m not getting what’s most important for you here. Can you help me out?

Process comments bring collaboration and immediacy as the therapist and client stop talking about “others out there, back then” and begin talking instead about “you and me, right now.” Process comments also give trainees a way to highlight faulty relational patterns, and a way to intervene and change problematic scenarios as they are occurring by clarifying and responding differently than their schemas dictate. To illustrate this experiential relearning: T: I’m wondering if something important might be going on between us right now? I know people don’t usually talk so directly, but maybe it could help us understand what’s been going wrong with others as well. Did we become disengaged when I said that? What do you think?

Interpersonal Feedback

In addition to activating stalled relationships and altering mal- adaptive relational patterns, instructors need to role play how process comments give clients useful interpersonal feedback that others are reluctant to provide. This type of process comment may highlight contradictions, incongruities, or mixed messages in what the client just said; acknowledge the unspoken subtext or embed- ded relational statement about “you and me” in what was just said; or help clients recognize discrepancies between what they are saying and doing: T: You are telling me such a sad thing, Paul, but you are saying it in an off-handed way—as if it doesn’t really matter. Help me understand the two different messages I’m get- ting—such a heartbreaking story being told in a half-interested manner? As we have been emphasizing, the significant challenge for instructors is to help their trainees grasp that the input they are giving is helpful and effective if given diplomatically and sensi- tively. However, doing so collides with the interpersonal coping strategies many trainees bring—to be “nice,” and avoid potential interpersonal conflict or disapproval—at any cost. Many trainees cannot adopt a process-oriented approach unless instructors pro- vide a sustained focus on working through this pervasive counter- transference propensity.

Metacommunication and Therapeutic Impact Disclosure

Clearly, these here-and-now interventions that address “you- and-me” break the social rules and often make trainees anxious.

However, they also make the therapeutic relationship more mean- ingful—they foster the Working Alliance and uncover what’s really wrong for the client, and give trainees the opportunity to provide reparative experiences. For example, Donald Kiesler, a pioneer in this work, discusses “therapeutic impact disclosure.” With this type of process comment, the therapist uses her own immediate experience of the client— or what is going on between them right now—to provide feedback about how the client’s way of relating is affecting the therapist (and likely others, too; Kiesler & Van Denberg, 1993). Here, the therapist is disclosing selectively chosen feedback about the impact this client is having on her at this moment—which some refer to as the therapist’s “Use-of-self”: T: I’m feeling like you are jumping from topic to topic, Jasmine, and I’m having trouble keeping up. I’m losing the point you’re trying to make. Is this something that just goes on between us sometimes, or have others told you that they feel confused or have trouble following you, too? What are your thoughts as I wonder about this?

Closely related, object relations and communication theorists “metacommunicate” to provide feedback about their current inter- action, especially as a way to register the unspoken emotional quality of a relationship. T: I could be wrong about this, Pat, but I have a feeling I would like to check out with you. Sometimes I feel if I disagree with you, you’ll be angry and leave. You know, if I see something differently, you’ll walk out the door at the end of the session and I won’t see you again. Is this just me or is there something to it? Here again, the challenge for instructors is to reframe straight talk as helpful to clients and not disrespectful—as it was often framed in their families of origin. Thus, instructors need to have trainees practice and rehearse safe and supportive ways to make these all-important (but often unspoken) relationally defining messages overt, rather than avoid them and act as if nothing important is occurring.

Self-Involving Versus Self-Disclosing Statements

In the counseling literature, “self-involving statements” center on Use-of-Self. Whereas self-disclosing statements refer to the therapist’s own past or personal life experiences (e.g., T: My father did that, too . . .), self-involving statements express some of the counselor’s selected thoughts or filtered emotional reactions to what the client has just said or done. Self-disclosing comments often take the client’s focus away from her own experience and shift it onto the therapist—which is especially familiar and prob- lematic with clients who were parentified or have a preoccupied attachment style. In contrast, self-involving statements keep the focus on the client and reveal information about what is happening in the relationship or how something the client has said or done is affecting the therapist: T: No, I don’t feel “judgmental” about what you did with him Saturday night, but I am concerned about your safety and how you put yourself in situations where you could be hurt.

Sharing certain personal reactions to what clients have just said or done conveys personal involvement and resonance, and strengthens the Working Alliance. T: I’m feeling uncomfortable, Bob. You’re talking in a loud, angry voice right now. How do

1 Throughout this article, clients’ personal information is disguised and clients are not identifiable.

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others usually respond when you do this? Therapists offer clients a gift when they provide such invaluable interpersonal feedback, which others have shrunk from sharing. Our aim as instructors is to help trainees find supportive, noncritical ways to help clients see themselves from others’ eyes, learn about the impact they have on others (such as regularly making others feel intimidated, over- whelmed, bored, and so forth), and function better by developing greater reflective capacity (Fonagy, Gergely, Jurist, & Target, 2002). Trainees need instructors to respond empathically to their anxiety as they begin to make self-involving statements. Here again, new therapists fear offending the client because they were socialized to believe that “nice” people don’t approach conflict. However, instructors can teach trainees how to enhance reflective capacity in their clients by role playing how effective therapists are willing to take the personal risk to explore with clients, thought- fully and always with the intention to safeguard the client’s self- esteem, what others may be feeling and thinking but don’t want to risk saying.

Use-of-Self to Provide CEEs

As we continue to see, it is often anxiety arousing for new therapists to use themselves and begin working in this more forthright way— especially for trainees who grew up in authori- tarian or dismissive families. Instructors can assure trainees that as they become more experienced and confident, it will become far easier for them to take the risk of “not knowing” and explore more open-endedly what may be occurring in the client–therapist rela- tionship. Here we are talking about “Use-of-Self.” When feeling confused or stuck, for example, more confident therapists can share their questions and concerns—filtered parts of their own internal dialogue—with the client. For example, T: I felt like we were engaged and working well together at the beginning of the hour. But now it feels like something has changed—as if I lost you somewhere. Is this my misunderstanding, or maybe you’re feeling that something’s not quite right either? What’s going on for you as I wonder about this? With such Use-of-Self, trainees often have the best opportunity to make their most significant interventions: T: Right now, I’m wondering if you might be thinking that I, too, want you to “just forget about this and let it go”—like your mother said when you told her that your Uncle had molested you. C: Well of course you do—isn’t that what therapists always do—tell you to forgive and forget or you’ll never get over it! T: Oh no, I’m not thinking that at all. I support this strong part of you that doesn’t want to give in to the denial and go along with the pressure to stop disrupting the family . . . In this way, Use-of-Self can often lead to significant corrective experiences. Initially, many trainees will not grasp the significance of this interaction, however, and instructors need to highlight the profound meaning and impact that is under- way in this exchange.

“But What if the Process Comment Doesn’t Work?”

Trainees frequently fear that the client will misunderstand their good intentions and feel awkward, blamed, or criticized by their process comment. Trainees need instructors to register and be empathic to this concern—and address it in depth. Many trainees will have a preoccupied attachment style, and this fear will be a cardinal issue for them. The preoccupied trainee is anxiously

worried about doing “something wrong” or “making a mistake” that will make the client disapprove of them or leave their rela- tionship. This anxious insecurity has pervaded their lives, and they have defended against it by adopting a pleasing interpersonal coping style. However, this is contrary to the forthright commu- nication that process comments require. If forthright communica- tion does make the client uncomfortable, as it could occasionally, trainees will need instructors to behaviorally demonstrate how they can restore the rupture by addressing it with the client, and sort it through. T: I’m wondering if you misunderstood me right there and felt I might be criticizing you, too? C: Well, yeah . . . T: Thank you so much for telling me that. What I was actually trying to convey was . . . Making this misunderstanding overt and restoring the rupture will be an important reparative experience for almost all clients. Here clients find that they can actually resolve conflict and “reconnect” with others—which they typically have not been able to do with spouses and significant others or, developmentally, when conflict threatened ties with their own attachment figures. T: You just interrupted me again, and I said this seems to occur often. That’s a very direct thing for me to say, and maybe you disagree or didn’t like me saying that? Can we talk about how it was to hear me say that? C: Well, I don’t like hearing that, but maybe I do interrupt. That’s how we talked in my family—I never could finish a sentence . . . nobody could.

Process Comments: A Common Denominator of Effective Therapists

Relationally oriented instructors aim to help new trainees begin exploring process comments with their clients and invite dialogue about what might be going on between them. Rather than focus solely on the content of what they are talking about, the therapist can “wonder aloud” and tentatively inquire about how they seem to be responding to each other or interacting together (i.e., their process). As we are emphasizing, many trainees initially struggle with process comments for fear of appearing “confrontational”— even if they already recognize many instances when this could be helpful: T: (internal dialogue) OK, I can see that he’s talking to me right now just like he does to everyone else. Great, I’m getting just as frustrated as they do. But how can I possibly bring this up without alienating him . . .?!

When instructors initially introduce process comments, trainees often misconstrue them. Trainees with a secure attachment style usually find it easy and congruent to work in this personal and forthright manner. In contrast, dismissive trainees commonly mis- construe the instructor’s emphasis on empathy and collaboration as being superficially “nice” or even “weak.” Fearful–avoidant train- ees will be highly ambivalent about the instructors’ invitation to speak directly with clients about their current interaction. On the one hand, it once evoked intense anxiety or even dread to break the “rules of attachment” and speak directly about the serious prob- lems or maltreatment that was occurring, and fail to comply with familial rules and keep secrets. On the other, the instructor’s permission to have a voice and “say what you see” is nothing less than a liberation that offers hope for a new way to live. Most commonly, however, trainees will be preoccupied and misconstrue process comments as confrontational and threatening to relational ties. Most trainees, sadly, have lacked role models who spoke to them in this straightforward yet empathic manner that the instruc-

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tor is introducing. Below, we further illustrate process comments and show how they may be used in differing relational interven- tions.

(1) We think of process comments as a basic stance toward the client that reflects a broadly relational method of treatment. They invite the therapist to intervene and work on the client’s problems within the immediacy of the therapist– client relationship. At the beginning of treatment, for example, trainees can speak directly with clients about their current interaction as they use accu- rate empathy to establish a Working Alliance by repeat- edly giving clients the experience that, “My therapist gets me”: T: As I listen, it sounds like you felt com- pletely erased when he said that—as if you didn’t exist. Am I getting that right, or can you help me capture it better? With this type of process comment, accurate empathy becomes more of a collaborative interpersonal process than a personal characteristic of the therapist.

(2) For relationally oriented trainees, learning how to talk about what’s going on between “you-and-me” also helps clients enter into treatment successfully. It helps thera- pists both recognize and respond to potential signs of resistance or ambivalence about entering therapy: T: I see our time is almost up, and I’m wondering how it’s been for you to talk with me today? It would help if we could talk about what’s felt good to you in this first session, and what hasn’t been so helpful that we might do differently next time? C: Well, I have liked talking with you, but in my culture, we don’t talk to others about family problems . . . Commonly, such process comments effectively reveal clients’ ambivalence about continuing treatment and make this a topic that can be sorted through rather than acted out. Such responses address the long-standing problem that approximately 30% of clients drop out after the initial intake, and 40% to 60% drop out prematurely in the first three to six sessions without achieving any therapeutic benefit (Cal- lahan & Hynan, 2005). In this way, the best time to use process comments is when the therapeutic relationship is struggling, the Alliance is threatened, or most simply, when the therapist is not liking the way in which the therapist and client are interacting together.

(3) We believe a common feature across relational ap- proaches is to break the social rules and help clients move beyond surface topics or talk primarily about others, and offer instead bids to enter their own feelings, concerns, and reactions more fully. Intervening directly within the therapeutic relationship can also be a produc- tive way to help clients focus internally on their own experience: T: You know it feels to me like we are arm wrestling a bit. You keep talking about what others are doing, and I keep asking instead about what you are thinking or how you wanted to respond. Let’s put our heads together and figure this out—what do you see going on between us? Trainees need instructors to model ways to engage more directly with clients’ sub-

jective feelings and concerns, rather than colluding with them in staying on surface topics and providing well- intended but superficial reassurances and problem- solving advice.

(4) As instructors, we try to help new relational therapists overtly invite and welcome the full intensity of what- ever feelings the client is experiencing into the im- mediacy of the therapist– client relationship (Green- berg, 2002). Oftentimes, the most significant way therapists can respond to the client’s strong feelings is through Use-of-Self and self-involving statements or selective disclosure of personal reactions: T: I can see how much this has hurt you, and how sad you’re feeling. I feel connected with you right now, and hope you’re not feeling alone as you said you have felt in the past. How is it for you to risk sharing this special part of yourself with me? C: I am sad, but this is different—I’m not alone with it . . . Responding in this new and different way to the client’s feelings often provides a CEE.

(5) Another common feature across relational therapies is to provide interpersonal feedback. Instructors want to help trainees draw on Use-of-Self and use some of their own reactions toward the clients to intervene with feedback about the impact the client is having on them and possibly others: T: May I have permission to share some feedback with you about how you come across to me at times—and perhaps others too? Maybe you’re not so aware of how this may affect others, but right now you are . . . Can we look at this together? Here again, we see that training relationally oriented therapists is challenging and complex. In- structors are asking trainees to respond in new and different ways that violate familial and cultural rules. This can engender significant anxiety—which can be difficult for instructors to help trainees contain in the beginning.

(6) Collaboratively exploring and trying to understand the current interaction between the therapist and the client facilitates work with transference or schema/ IWM distortions: T: How do you think I am going to react if you decide to do that? What am I going to be thinking or feeling toward you? C: Well, you’ll act nice, but I know you’ll really be judging me . . . Early in their training, it seems unimaginable for many new therapists to ever pose such a question. However, process comments like this are powerful uncovering techniques. They highlight the client’s IWMs—their pathogenic beliefs about themselves and faulty ex- pectations of the therapist and others—which helps to clarify the treatment focus. Instructors often have difficulty teaching trainees how to develop a treat- ment focus. Process comments, which inquire about the client’s perceptions of the therapist’s thoughts and reactions, reveal the client’s key concerns and

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help both therapist and client discern what’s really wrong.

(7) To facilitate the Working Alliance, the therapist’s role is to sustain an empathic, respectful, and inter- ested attitude toward the client. However, this em- pathic stance routinely falters, as “ruptures” in the Working Alliance commonly occur (Safran et al., 2009). Alliance ruptures occur for different reasons: because of hostility from angry, provocative, or con- trolling clients (referred to as “Client Negativity”); reenactments that some clients re-create that embroil the therapist in familiar, but problematic, relational scenarios; and the simple human misunderstandings that occur in every meaningful relationship. Let’s see how process comments can help.

Beginning with the problematic but often ignored topic of Client Negativity, being irritable, demanding, or critical are defining diagnostic features for many clients. Most trainees haven’t antic- ipated receiving this “negativity” as part of their new career. However, some clients will be dominating, intrusive, competitive, sexualizing, and so forth with their therapist—just as they are with others. Additionally, some clients are going to elicit or “pull” therapists into argumentative, distancing, rescuing, and other types of familiar conflictual exchanges. Disturbingly, however, research- ers find that even experienced therapists tend to respond “in kind” toward the client with their own countercriticism, judgmentalism, punitiveness, or withdrawal. When these “complementary” re- sponses occur, it leads to poor treatment outcomes. Thus, core conditions of empathy are quickly lost as clients with angry, distrustful, or rigid interpersonal styles successfully evoke coun- tertherapeutic hostility and control— even with highly trained and experienced therapists (Binder & Strupp, 1997). Here again, pro- cess comments give us effective ways to respond to the common but often avoided issue of Client Negativity: T: You’ve just criticized me there, Susie, and I’ve felt that a few times before. Help me understand how others usually respond when you do that? With Use-of-Self, instructors can help trainees reflect on and use their negative reactions to ask themselves (internally): Right now, I’m feeling like withdrawing. This isn’t just my issue, I’m hearing that she is making others feel this way too. How can I find an effective way to help her see the impact she is having on others?

Even with clients who present as “agreeable,” simple misunder- standings occur at points in most therapeutic relationships. Unfor- tunately, researchers find that clients often do not voice their concerns and bring up the problems they are having with their therapists, and, creating an unwanted cycle, therapists often avoid or do not ask about them (Hill, Thompson, Cogar, & Denman, 1993). Clearly, many new and experienced therapists are person- ally uncomfortable and avoid approaching interpersonal conflict. It is imperative that instructors prepare trainees to expect, verbally acknowledge, and work to restore disrupted relationships. Unac- knowledged and unresolved misunderstandings between client and therapist are not benign—they undermine the Working Alliance and lead to poor treatment outcomes (Johnson et al., 1995). Rather than ignoring the conflict, or responding in kind with countercrit- icism, blame, or disengagement, process comments give therapist a relationally affirming way to address the problem as it is occur-

ring. Instructors can role play with trainees how to neutrally observe or tentatively wonder aloud about potential problems or misunderstandings that may occur: T: Right now, it feels to me as though I keep doing the wrong thing. You keep asking for help but, when I offer suggestions, you say “Yes, but . . .” Let’s work this out—what do you see going on between us?

Treatment stalls unless therapists and clients can talk about problems in their relationship and sort them through. Working them out as they arise provides a valuable social laboratory where clients can learn how to address and resolve conflict with others. However, most new therapists find it far easier to be supportive than to inquire about potential conflict between “you-and-me” or try to sort through problems directly. As with their clients, many trainees did not learn to address or resolve problems in their families of origin where, too often, there was no secure mechanism to restore the ruptures that occurred with their own attachment figures. And, as emphasized, many trainees grew up in families that held strong but often unspoken rules against addressing prob- lems openly, or witnessed conflict escalate in hurtful ways. In sum, instructors need to rehearse with trainees nondefensive ways to respond to interpersonal conflict.

Empowering New Therapists to Work With the Process Dimension

As instructors, we need to appreciate how anxiety arousing it can be for new therapists to “jump off the cliff,” and say, for example, T: I’m wondering if you ever find it hard with me, too, to speak up and say what you think or want? It will make sense to some new therapists that what tends to go wrong for clients in other relationships will also come into play with the therapist at times, and that it could be helpful to talk together about that. As emphasized, however, process comments will be challenging in the beginning. Many trainees have little confidence and, under- standably, are reluctant to have what little self-confidence they may possess shaken by stepping outside of familiar bounds. And, even if they think this type of intervention might be useful, they often struggle to discern whether they are objectively observing the client’s behavior or if their perceptions reflect their own countertransference: T (internally): Is this just me, or does she make everybody feel this way?

Instructors need to encourage trainees to “wait and see” if this is a pattern that recurs. Trainees are advised to consult a supervisor before sharing their observation in session in order to distinguish countertransference from clients’ maladaptive behavior. Neverthe- less, most trainees feel unsure of how to bring up what they are considering, and to find a helpful or diplomatic way to make this overt—without making the client feel criticized or blamed. And, of course, all have seen directness used hurtfully—in angry confron- tations or blaming personal attacks intended to win arguments, put someone down, or induce shame or guilt. Therapists never want to do any of this, of course. Diminishing clients’ self-esteem or sense of safety in these unwanted ways will impede clients’ ability to make progress in treatment. Instructors can demonstrate how to use process comments in collaborative and respectful ways that help trainees earn credibility, rather than make clients feel awk- ward or confronted. Observing instructors is essential because the communication is more in the nonverbals than in the words used.

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Process comments will be effective when the therapist’s tone is respectful—and ineffective if it is critical or condescending.

Instructors will often observe a two-step sequence with their trainees when, at first, trainees find they are beginning to recognize the process dimension and see when something important is going on between them. Second, however, it usually takes more time until trainees feel confident enough to speak up and begin explor- ing the process dimension. Instructors help when they validate trainees’ reality-based feeling that it is something of a personal risk to suggest: T: I’m curious about something that might be going on between us right now, and wondering if . . . What are your thoughts about this possibility? Although trainees will be accurate with some of their process observations, others will not resonate with clients. Trainees have not failed in any way or made a mistake when the observation they have tentatively suggested doesn’t fit; they are just making a respectful attempt to understand and help, and most clients will appreciate these good intentions. The aim here is not to be “right.” Instead, trainees are trying to initiate a mutual dialogue with the client—so together they can explore and learn from what may be going on between them: T (nondefen- sively, in a friendly and welcoming tone): OK, what I’m suggesting doesn’t quite fit. Help me say it more accurately. What are your words for what might be going on between us?

Nevertheless, trainees should not be in a hurry to make process comments until they feel ready to do so. Typically, it takes a year or so before trainees feel comfortable saying what they see and venturing this with clients. Further, instructors want to encourage trainees to respect their own sense of timing and listen to their own feeling that, “This just isn’t going to work right now” versus “Now might be a good time to say this.” It’s important that trainees choose when and how to make these interventions.

Instructors also help trainees by jointly conceptualizing what has gone awry for the client in other relationships, and consider how similar relational themes might play out in the way they are interacting together. Formulating these “working hypotheses” helps trainees anticipate the types of faulty expectations, schema- driven distortions, and reenactments that this client may be prone to play out, and therefore be better prepared to respond to what this particular client is likely to present in treatment. In this way they can better “see” what is going on between them and “hear” what the client is really saying—as the client is saying it, rather than “getting it” later (e.g., trainee reviewing videotape thinks to him- self: “Right there she’s telling me that everybody feels over- whelmed by her. She’s probably telling me she’s worried that I’m feeling that way, too. Why do I get it now, and not then when she’s saying it?!”).

In sum, working hypotheses go far in helping trainees make sense of their own experience in the hour and better grasp what is transpiring in their interpersonal process as it is occurring. When trainees find themselves reacting toward the client in unwanted ways, such as feeling bored, discouraged, argumentative, and so forth, their working hypotheses will expand their reflective capac- ities and help them be nondefensive and consider ways problem- atic relational patterns may be being reenacted. This is also a good time to consult with a supervisor about process comments they may want to venture, in order to begin exploring their subjective reactions and working hypotheses with the client. Trainees cannot attempt process-oriented interventions without active guidance from a supportive supervisor. As trainees become less concerned

about performance anxieties, and supervisors help them under- stand where they are trying to go in treatment with this particular client, they will find how helpful it is when they can link aspects of the problem the client is talking about with others to their current interaction—and begin changing this in their relationship first.

To ease the transition toward more forthright engagement, in- structors can help trainees provide contextual remarks that facili- tate the bid for more open or authentic communication. For ex- ample, the first time the therapist addresses the process dimension, the therapist can create safety for the client by offering an intro- ductory remark that acknowledges the shift to a different type of discourse: T: May I break the social rules for a minute and ask about something that might be going on between us?

Therapists will not alienate clients if they respond respectfully, share their observations tentatively (e.g., Sometimes I find myself wondering if . . .), invite collaboration (e.g., “What do you think?”), and provide these types of transition comments. These contextual remarks help clients understand the therapist’s good intentions, as they help clients shift from surface conversation to a more straightforward approach that invites deeper personal en- gagement. Rather than being threatened by this invitation, most clients will welcome and be reassured by this bid to talk about what’s really wrong. All agree—these present-centered interven- tions that bring a greater level of engagement and intensity are the most anxiety-arousing for new therapists to adopt (Hill, 2009). To use the process dimension effectively, instructors need to help trainees do two things. First, they must balance the challenge of metacommunication with being supportive and protective of cli- ents’ self-esteem (Kiesler, 1996). Process comments, like any other interventions, can be made in blunt, accusatory, or otherwise ineffective ways. Warmth, tact, curiosity, and a sense of humor can all go a long way toward making every intervention more effec- tive. Second, trainees can check in with their clients and talk about the process intervention they just made: (T: How was it for you when I said that? I know people don’t usually speak so directly about what’s going on between them). In the initial session, we educate clients about the treatment process by explaining that we will try to help by speaking forthrightly and, in turn, we invite them to speak up and express any concerns about us or treatment directly. Then, we also inquire, “How would it be for you to talk with me in this more straightforward manner?”

Let’s now explore countertransference further and other situa- tions when process comments will not work. Trainees do not want to jump in with process comments in a spontaneous or cavalier manner. They want to be thoughtful about when and how they use these powerful interventions, and always consider the possibility that their own observations or reactions may reflect more about their own countertransference than it does about the client or their interaction. As a rule of thumb, experienced therapists usually wait to comment until they have seen an interaction occur two or three times. When in doubt about whether an observation has more to do with the therapist or the client, it is best to wait, gather additional observations, and consult a supervisor before raising the issue with the client. Again, all process comments are simply observations— offered tentatively, as possibilities for mutual clarification, not as truth or fact. Differentiating the client’s concerns from the thera- pist’s own personal issues is one of the most important compo- nents of clinical training.

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By looking honestly at their own contribution to problems or misunderstandings, trainees facilitate an egalitarian relationship that holds genuine meaning for both. However, this increasing mutuality may activate trainees’ own personal problems or coun- tertransference at times (Yalom & Leszcz, 2005). In order to work relationally, however, trainees need to relinquish hierarchical con- trol over the relationship, which can arouse anxiety for trainees who need to be the authority or personally distanced in the role of expert. Additionally, trainees may be concerned that this genuine responsiveness, emotional presence, or egalitarian stance will lead to a loss of appropriate therapeutic boundaries and result in over- involvement or acting out. One of the most important functions of supervision is to help trainees track this interpersonal process and recognize when their own countertransference is prompting them to become overidentified with— or too distant from—the client. Countertransference is most likely to create problems when train- ees disregard it. Trainees who are aware that they are always susceptible to countertransference, and explore this with their supervisors, should feel unfettered about working in a process- oriented manner.

In closing, the primary concern for trainees about making pro- cess comments is concern about appearing confrontational—fear- ing clients will feel “confronted” in some aggressively challenging or exposing way. Trainees do not want to be confrontational just as most clients do not want to be confronted. However, a process comment, if used sensitively, seeks to communicate forthrightly yet empathically and without blame or disrespect. Instructors help trainees by clarifying that if they think the process comment they are considering making is going to lead the client feel confronted or blamed, don’t make it. Instead, trainees can wait for another time that feels better or, better yet, (with Use-of-Self) make a different process comment and talk with the client concerning their reservations about sharing this observation: T: There’s something I’m thinking about right now, but I’m feeling unsure about ad- dressing it with you. I’m concerned you might misunderstand my good intentions, and feel criticized or blamed, which I certainly don’t want. May I ask for permission to speak frankly with you?

The goal with process comments, as with relationally oriented therapies in general, is to create a new and reparative relationship for clients where it’s safe to talk about their distress and whatever matters most to them—which includes how understanding and changing what’s going on between “you and me” is often the best way to begin changing what’s wrong with others.

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Received February 25, 2014 Accepted February 28, 2014 �

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