Working With the Process Dimension in Relational Therapies: Guidelinesfor Clinical Training

Edward Teyber and Faith McClure TeyberCalifornia State University

This article offers guidelines for training relationally oriented therapists. We highlight core concepts thatare widely used across relationally oriented therapies. We focus on the process dimension and thetherapeutic relationship, and illustrate how process comments are the moderator variable that makes eachof the core concepts more effective. Guidelines are provided for clinical instructors to help their traineesuse these challenging, but potent, interventions that bring intensity to the therapeutic relationship andhelp 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 helpingclients and training therapists. Combined, we have been practicingrelationally oriented therapies for over 75 years. Long ago, weboth entered graduate school with interests in child therapy—sustaining core sensibilities that are evident in the attachment-informed, developmental, and familial perspectives that still guideus 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 ofthese traditions. Like many, we see more similarities than differ-ences across relational approaches, and we are heartened by thepioneering work of Stephen Mitchell (1988) and many othertheorists 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 moreuniversal relational orientation and shared identity among clini-cians—and we are honored to participate in this effort towardself-definition.

Our approach links core treatment concepts, widely used acrossrelationally oriented therapies: the Working Alliance; Rupture andRepair; Attuned Responsiveness and Empathic Understanding; theInternalization 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, webelieve that clients change in treatment by finding a correctiveemotional 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 anddistress) and a “secure base” (active support for their individuationand 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 hereon what we believe to be the most far-reaching but challengingtopic: How relationally oriented therapists can use “process com-ments” to make each of these relational treatment constructs moreeffective. We believe the focus on process—on the here-and-nowinteraction between the therapist and client—is not just one ofmany possible interventions; it is an indispensable common de-nominator of effective therapists and links together relationallyminded clinicians (Yalom & Leszcz, 2005). Process comments areforthright, but collaborative, bids from therapists to explore what ismost salient about what is occurring between them right now.However, here is the bind we have long struggled with as clinicalinstructors. 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 away to enter the client’s distress and engage directly with theircore concerns. However, they are unfamiliar and often intimidat-ing to new therapists, and challenging both for instructors to teachand for trainees to adopt. Thus, the purpose of this article is tohighlight common difficulties that process-oriented interventionsevoke for many trainees and provide guidelines for instructors tohelp with trainees’ anxiety about working within the relationshipand with such immediacy. Trainees cannot adopt these process-oriented interventions about “you-and-me” by just reading articlesor discussing them in class—they need instructors to role play ordemonstrate them before they can begin to say, “Oh, that’s whatyou mean” or, better yet, “Yeah, I can do that.” Without thesebehavioral role models that help trainees “see” these challenginginteractions, too many promising trainees will turn away becauseof the ambiguities and feelings of inadequacy that are commonlyevoked by using immediacy interventions. Anxious trainees mayturn toward more prescriptive therapies that focus solely on thepresenting problem. These manualized approaches are reassuringbecause they provide more structure and direction—but offer lessbecause they do not conceptualize or intervene with clients’ prob-lems in a relational context. Instructors aim to empower studenttherapists 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, CaliforniaState University, San Bernardino, CA 92407. E-mail: eteyber@csusb.edu

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

Psychotherapy © 2014 American Psychological Association2014, Vol. 51, No. 3, 334–341 0033-3204/14/$12.00 DOI: 10.1037/a0036579

334

and social rules. Here they invite clients to explore together whatmay be going on in their relationship that may inform what is alsogoing wrong in their personal lives. Thus, our goal is to helpinstructors overcome trainees’ anxiety about utilizing themselvesand 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 guidingtreatment 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 canbe resolved within therapeutic relationships. In this way, acardinal concept across relational therapies is the CEE (Cas-tonguay & Hill, 2012). To effect change, relational therapistsare trying to disconfirm or expand Internal Working Models(IWMs) and avoid replaying in treatment what has gone wrongin other important relationships— especially along the processdimension or way in which the therapist and client are inter-acting together. Although such reenactments are inevitable attimes, 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 tochange them by making them overt and talking them throughwith the client. Providing this experience of change—that somerelationships can now be different and not go down familiar,expected but unwanted lines—is a core component of change inrelational approaches (Teyber & McClure, 2011).

Further, empathic attunement (relatedness) coupled with supportfor differentiation (separateness) also allows the therapist to pro-vide clients with a new and corrective response to the problematicpatterns than they have experienced with important others in thepast—and come to expect in current relationships. Change occursas 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 beingslotted into problematic schemas, or if it disconfirms familiartemplates and provides new relational options.

Teaching Trainees to Use Process Comments andIntervene in the Moment

We look now at a group of closely related interventions thattherapists can use to work in the moment and use the therapeuticrelationship as the primary vehicle to facilitate change and providea CEE. Therapists within diverse relational approaches have writ-ten about these interventions—and termed them metacommunica-tions, immediacy interventions, and so forth. However, we preferto follow Irvin Yalom working in a group psychotherapy modality,and Virginia Satir and other early family systems theorists, whocall these interventions “process comments.” We will see belowthat 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 thetherapist’s “Use-of-Self” to intervene in the here and now and talkwith clients about what may be going on between them in theircurrent interaction. For example, Therapist (T): “I just broacheda sensitive topic, and I’m wondering how you are feeling about medoing that?” Our aim is to help relationally oriented trainees learnhow to use process comments to: Help clients enter treatment witha lower drop-out rate; Establish and sustain a stronger workingalliance; Address resistance and schema distortions; Clarify theclient’s problems with more specificity and better discern a treat-ment focus; and Restore ruptures. Process comments link thesewidely appreciated relational interventions and make each of themmore potent. They allow therapists to engage clients in far moremeaningful ways and, when used compassionately, bring aboutmore genuine and collaborative relationships. We also believe that,across treatment approaches, the “capacity to engage” is a definingtherapist variable that differentiates more and less effective ther-apists within each treatment brand—and process comments helpcreate meaning and enhance therapist–client engagement (Teyber& McClure, 2000).

Process comments make the interaction between the therapistand client overt and put the relationship “on the table” as a topicfor discussion. There is a distinction between the overtly spokencontent of what is discussed and the process dimension of howthe therapist and client interact. The single biggest challenge forinstructors is to help trainees contain their anxiety and workthrough how process comments often conflict with their famil-ial rules and cultural prescriptions. Instructors wish to invitediscussion about how unacceptable it was for most trainees tobreak the social rules and talk with family members about “youand 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 bydoing two things. First, instructors want to discourage traineesfrom using these types of interactions in their personal lives,where they often will not be well-received. Second, instructorsneed to be aware that many trainees will inaccurately slot theirdiscussions about these process interventions into their ownfamiliar, but problematic, developmental experience of beingpainfully confronted, put on the spot, or intruded upon. Thus,instructors want to clarify that these process interventionsshould 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 ownexperience of the client to wonder aloud about what might begoing 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 (“Itsounds like . . .”; “I’m wondering if . . .”; “Maybe . . .”) aremore effective than direct challenges (“I think you . . .”; Miller,Benefield, & Tonigan, 1993). Let’s illustrate how therapists canuse process comments with “skillful tentativeness,” as an invi-tation to explore their relationship: T: As you’re talking abouthim and what went on between you two, I’m wondering if youmight be saying something about our relationship as well? Doesthat ever come up between us, too? Client (C): Well, yeah,you’re the therapist—you’re always in control of what goes on

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

335TEYBER-PROCESS

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

Activating Stalled Relationships and AlteringMaladaptive Patterns

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

Process comments bring collaboration and immediacy as thetherapist and client stop talking about “others out there, back then”and begin talking instead about “you and me, right now.” Processcomments also give trainees a way to highlight faulty relationalpatterns, and a way to intervene and change problematic scenariosas they are occurring by clarifying and responding differently thantheir schemas dictate. To illustrate this experiential relearning:T: I’m wondering if something important might be going onbetween us right now? I know people don’t usually talk so directly,but maybe it could help us understand what’s been going wrongwith 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 howprocess comments give clients useful interpersonal feedback thatothers are reluctant to provide. This type of process comment mayhighlight contradictions, incongruities, or mixed messages in whatthe 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 aresaying and doing: T: You are telling me such a sad thing, Paul, butyou are saying it in an off-handed way—as if it doesn’t reallymatter. Help me understand the two different messages I’m get-ting—such a heartbreaking story being told in a half-interestedmanner? As we have been emphasizing, the significant challengefor instructors is to help their trainees grasp that the input they aregiving is helpful and effective if given diplomatically and sensi-tively. However, doing so collides with the interpersonal copingstrategies many trainees bring—to be “nice,” and avoid potentialinterpersonal conflict or disapproval—at any cost. Many traineescannot adopt a process-oriented approach unless instructors pro-vide a sustained focus on working through this pervasive counter-transference propensity.

Metacommunication and TherapeuticImpact 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’sreally wrong for the client, and give trainees the opportunity toprovide reparative experiences. For example, Donald Kiesler, apioneer in this work, discusses “therapeutic impact disclosure.”With this type of process comment, the therapist uses her ownimmediate experience of the client—or what is going on betweenthem right now—to provide feedback about how the client’s wayof relating is affecting the therapist (and likely others, too; Kiesler& Van Denberg, 1993). Here, the therapist is disclosing selectivelychosen feedback about the impact this client is having on her atthis 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’retrying to make. Is this something that just goes on between ussometimes, or have others told you that they feel confused or havetrouble following you, too? What are your thoughts as I wonderabout 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 emotionalquality of a relationship. T: I could be wrong about this, Pat, butI have a feeling I would like to check out with you. Sometimes Ifeel 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 endof the session and I won’t see you again. Is this just me or is theresomething to it? Here again, the challenge for instructors is toreframe straight talk as helpful to clients and not disrespectful—asit was often framed in their families of origin. Thus, instructorsneed to have trainees practice and rehearse safe and supportiveways to make these all-important (but often unspoken) relationallydefining messages overt, rather than avoid them and act as ifnothing important is occurring.

Self-Involving Versus Self-Disclosing Statements

In the counseling literature, “self-involving statements” centeron Use-of-Self. Whereas self-disclosing statements refer to thetherapist’s own past or personal life experiences (e.g., T: My fatherdid that, too . . .), self-involving statements express some of thecounselor’s selected thoughts or filtered emotional reactions towhat the client has just said or done. Self-disclosing commentsoften take the client’s focus away from her own experience andshift it onto the therapist—which is especially familiar and prob-lematic with clients who were parentified or have a preoccupiedattachment style. In contrast, self-involving statements keep thefocus on the client and reveal information about what is happeningin the relationship or how something the client has said or done isaffecting the therapist: T: No, I don’t feel “judgmental” about whatyou did with him Saturday night, but I am concerned about yoursafety and how you put yourself in situations where you could behurt.

Sharing certain personal reactions to what clients have just saidor done conveys personal involvement and resonance, andstrengthens 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 andclients are not identifiable.

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

336 TEYBER AND TEYBER

others usually respond when you do this? Therapists offer clientsa gift when they provide such invaluable interpersonal feedback,which others have shrunk from sharing. Our aim as instructors isto help trainees find supportive, noncritical ways to help clients seethemselves from others’ eyes, learn about the impact they have onothers (such as regularly making others feel intimidated, over-whelmed, bored, and so forth), and function better by developinggreater reflective capacity (Fonagy, Gergely, Jurist, & Target,2002). Trainees need instructors to respond empathically to theiranxiety as they begin to make self-involving statements. Hereagain, new therapists fear offending the client because they weresocialized to believe that “nice” people don’t approach conflict.However, instructors can teach trainees how to enhance reflectivecapacity in their clients by role playing how effective therapists arewilling 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 torisk saying.

Use-of-Self to Provide CEEs

As we continue to see, it is often anxiety arousing for newtherapists to use themselves and begin working in this moreforthright way—especially for trainees who grew up in authori-tarian or dismissive families. Instructors can assure trainees that asthey become more experienced and confident, it will become fareasier for them to take the risk of “not knowing” and explore moreopen-endedly what may be occurring in the client–therapist rela-tionship. Here we are talking about “Use-of-Self.” When feelingconfused or stuck, for example, more confident therapists canshare their questions and concerns—filtered parts of their owninternal dialogue—with the client. For example, T: I felt like wewere engaged and working well together at the beginning of thehour. But now it feels like something has changed—as if I lost yousomewhere. Is this my misunderstanding, or maybe you’re feelingthat something’s not quite right either? What’s going on for you asI wonder about this? With such Use-of-Self, trainees often have thebest 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 mothersaid when you told her that your Uncle had molested you. C: Wellof course you do—isn’t that what therapists always do—tell you toforgive and forget or you’ll never get over it! T: Oh no, I’m notthinking that at all. I support this strong part of you that doesn’twant to give in to the denial and go along with the pressure to stopdisrupting the family . . . In this way, Use-of-Self can often lead tosignificant corrective experiences. Initially, many trainees will notgrasp the significance of this interaction, however, and instructorsneed 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 theirgood intentions and feel awkward, blamed, or criticized by theirprocess comment. Trainees need instructors to register and beempathic to this concern—and address it in depth. Many traineeswill have a preoccupied attachment style, and this fear will be acardinal 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 theyhave defended against it by adopting a pleasing interpersonalcoping 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 theycan restore the rupture by addressing it with the client, and sort itthrough. T: I’m wondering if you misunderstood me right thereand felt I might be criticizing you, too? C: Well, yeah . . . T: Thankyou so much for telling me that. What I was actually trying toconvey was . . . Making this misunderstanding overt and restoringthe rupture will be an important reparative experience for almostall clients. Here clients find that they can actually resolve conflictand “reconnect” with others—which they typically have not beenable 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 occuroften. That’s a very direct thing for me to say, and maybe youdisagree or didn’t like me saying that? Can we talk about how itwas to hear me say that? C: Well, I don’t like hearing that, butmaybe I do interrupt. That’s how we talked in my family—I nevercould finish a sentence . . . nobody could.

Process Comments: A Common Denominator ofEffective Therapists

Relationally oriented instructors aim to help new trainees beginexploring process comments with their clients and invite dialogueabout what might be going on between them. Rather than focussolely on the content of what they are talking about, the therapistcan “wonder aloud” and tentatively inquire about how they seemto be responding to each other or interacting together (i.e., theirprocess). As we are emphasizing, many trainees initially strugglewith process comments for fear of appearing “confrontational”—even if they already recognize many instances when this could behelpful: T: (internal dialogue) OK, I can see that he’s talking to meright now just like he does to everyone else. Great, I’m getting justas frustrated as they do. But how can I possibly bring this upwithout alienating him . . .?!

When instructors initially introduce process comments, traineesoften misconstrue them. Trainees with a secure attachment styleusually find it easy and congruent to work in this personal andforthright manner. In contrast, dismissive trainees commonly mis-construe the instructor’s emphasis on empathy and collaboration asbeing superficially “nice” or even “weak.” Fearful–avoidant train-ees will be highly ambivalent about the instructors’ invitation tospeak directly with clients about their current interaction. On theone 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 withfamilial rules and keep secrets. On the other, the instructor’spermission to have a voice and “say what you see” is nothing lessthan a liberation that offers hope for a new way to live. Mostcommonly, however, trainees will be preoccupied and misconstrueprocess comments as confrontational and threatening to relationalties. Most trainees, sadly, have lacked role models who spoke tothem in this straightforward yet empathic manner that the instruc-

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

337TEYBER-PROCESS

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

(1) We think of process comments as a basic stance towardthe client that reflects a broadly relational method oftreatment. They invite the therapist to intervene andwork on the client’s problems within the immediacy ofthe therapist–client relationship. At the beginning oftreatment, for example, trainees can speak directly withclients about their current interaction as they use accu-rate empathy to establish a Working Alliance by repeat-edly giving clients the experience that, “My therapistgets 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 itbetter? With this type of process comment, accurateempathy becomes more of a collaborative interpersonalprocess than a personal characteristic of the therapist.

(2) For relationally oriented trainees, learning how to talkabout what’s going on between “you-and-me” also helpsclients enter into treatment successfully. It helps thera-pists both recognize and respond to potential signs ofresistance or ambivalence about entering therapy: T: Isee our time is almost up, and I’m wondering how it’sbeen for you to talk with me today? It would help if wecould talk about what’s felt good to you in this firstsession, and what hasn’t been so helpful that we mightdo differently next time? C: Well, I have liked talkingwith you, but in my culture, we don’t talk to othersabout family problems . . . Commonly, such processcomments effectively reveal clients’ ambivalence aboutcontinuing treatment and make this a topic that can besorted through rather than acted out. Such responsesaddress the long-standing problem that approximately30% of clients drop out after the initial intake, and 40%to 60% drop out prematurely in the first three to sixsessions without achieving any therapeutic benefit (Cal-lahan & Hynan, 2005). In this way, the best time to useprocess comments is when the therapeutic relationshipis struggling, the Alliance is threatened, or most simply,when the therapist is not liking the way in which thetherapist and client are interacting together.

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

jective feelings and concerns, rather than colluding withthem 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 therapistsovertly 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 waytherapists can respond to the client’s strong feelings isthrough Use-of-Self and self-involving statements orselective disclosure of personal reactions: T: I can seehow much this has hurt you, and how sad you’refeeling. I feel connected with you right now, and hopeyou’re not feeling alone as you said you have felt inthe past. How is it for you to risk sharing this specialpart of yourself with me? C: I am sad, but this isdifferent—I’m not alone with it . . . Responding inthis new and different way to the client’s feelingsoften provides a CEE.

(5) Another common feature across relational therapies isto provide interpersonal feedback. Instructors want tohelp trainees draw on Use-of-Self and use some oftheir own reactions toward the clients to intervenewith feedback about the impact the client is having onthem and possibly others: T: May I have permissionto share some feedback with you about how you comeacross to me at times—and perhaps others too?Maybe you’re not so aware of how this may affectothers, but right now you are . . . Can we look at thistogether? Here again, we see that training relationallyoriented therapists is challenging and complex. In-structors are asking trainees to respond in new anddifferent ways that violate familial and cultural rules.This can engender significant anxiety—which can bedifficult for instructors to help trainees contain in thebeginning.

(6) Collaboratively exploring and trying to understandthe current interaction between the therapist and theclient facilitates work with transference or schema/IWM distortions: T: How do you think I am going toreact if you decide to do that? What am I going to bethinking or feeling toward you? C: Well, you’ll actnice, but I know you’ll really be judging me . . . Earlyin their training, it seems unimaginable for many newtherapists to ever pose such a question. However,process comments like this are powerful uncoveringtechniques. They highlight the client’s IWMs—theirpathogenic beliefs about themselves and faulty ex-pectations of the therapist and others—which helps toclarify the treatment focus. Instructors often havedifficulty teaching trainees how to develop a treat-ment focus. Process comments, which inquire aboutthe client’s perceptions of the therapist’s thoughtsand reactions, reveal the client’s key concerns and

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

338 TEYBER AND TEYBER

help both therapist and client discern what’s reallywrong.

(7) To facilitate the Working Alliance, the therapist’srole is to sustain an empathic, respectful, and inter-ested attitude toward the client. However, this em-pathic stance routinely falters, as “ruptures” in theWorking 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 embroilthe therapist in familiar, but problematic, relationalscenarios; and the simple human misunderstandingsthat occur in every meaningful relationship. Let’s seehow process comments can help.

Beginning with the problematic but often ignored topic of ClientNegativity, being irritable, demanding, or critical are definingdiagnostic 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 withothers. Additionally, some clients are going to elicit or “pull”therapists into argumentative, distancing, rescuing, and other typesof 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, coreconditions 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 andexperienced therapists (Binder & Strupp, 1997). Here again, pro-cess comments give us effective ways to respond to the commonbut often avoided issue of Client Negativity: T: You’ve justcriticized 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 usetheir negative reactions to ask themselves (internally): Right now,I’m feeling like withdrawing. This isn’t just my issue, I’m hearingthat she is making others feel this way too. How can I find aneffective 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 theirconcerns and bring up the problems they are having with theirtherapists, and, creating an unwanted cycle, therapists often avoidor 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. Itis imperative that instructors prepare trainees to expect, verballyacknowledge, and work to restore disrupted relationships. Unac-knowledged and unresolved misunderstandings between client andtherapist are not benign—they undermine the Working Allianceand lead to poor treatment outcomes (Johnson et al., 1995). Ratherthan ignoring the conflict, or responding in kind with countercrit-icism, blame, or disengagement, process comments give therapista relationally affirming way to address the problem as it is occur-

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

Treatment stalls unless therapists and clients can talk aboutproblems in their relationship and sort them through. Workingthem out as they arise provides a valuable social laboratory whereclients can learn how to address and resolve conflict with others.However, most new therapists find it far easier to be supportivethan to inquire about potential conflict between “you-and-me” ortry to sort through problems directly. As with their clients, manytrainees did not learn to address or resolve problems in theirfamilies of origin where, too often, there was no secure mechanismto restore the ruptures that occurred with their own attachmentfigures. And, as emphasized, many trainees grew up in familiesthat 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 torespond to interpersonal conflict.

Empowering New Therapists to Work Withthe Process Dimension

As instructors, we need to appreciate how anxiety arousing itcan be for new therapists to “jump off the cliff,” and say, forexample, 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 tosome new therapists that what tends to go wrong for clients inother relationships will also come into play with the therapist attimes, and that it could be helpful to talk together about that. Asemphasized, however, process comments will be challenging inthe beginning. Many trainees have little confidence and, under-standably, are reluctant to have what little self-confidence theymay possess shaken by stepping outside of familiar bounds. And,even if they think this type of intervention might be useful, theyoften struggle to discern whether they are objectively observingthe client’s behavior or if their perceptions reflect their owncountertransference: T (internally): Is this just me, or does shemake everybody feel this way?

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

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

339TEYBER-PROCESS

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

Instructors will often observe a two-step sequence with theirtrainees when, at first, trainees find they are beginning to recognizethe process dimension and see when something important is goingon between them. Second, however, it usually takes more timeuntil trainees feel confident enough to speak up and begin explor-ing the process dimension. Instructors help when they validatetrainees’ reality-based feeling that it is something of a personal riskto suggest: T: I’m curious about something that might be going onbetween us right now, and wondering if . . . What are yourthoughts about this possibility? Although trainees will be accuratewith some of their process observations, others will not resonatewith clients. Trainees have not failed in any way or made a mistakewhen 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 aimhere is not to be “right.” Instead, trainees are trying to initiate amutual dialogue with the client—so together they can explore andlearn from what may be going on between them: T (nondefen-sively, in a friendly and welcoming tone): OK, what I’m suggestingdoesn’t quite fit. Help me say it more accurately. What are yourwords for what might be going on between us?

Nevertheless, trainees should not be in a hurry to make processcomments until they feel ready to do so. Typically, it takes a yearor so before trainees feel comfortable saying what they see andventuring this with clients. Further, instructors want to encouragetrainees to respect their own sense of timing and listen to their ownfeeling that, “This just isn’t going to work right now” versus “Nowmight be a good time to say this.” It’s important that traineeschoose when and how to make these interventions.

Instructors also help trainees by jointly conceptualizing whathas gone awry for the client in other relationships, and considerhow similar relational themes might play out in the way they areinteracting together. Formulating these “working hypotheses”helps trainees anticipate the types of faulty expectations, schema-driven distortions, and reenactments that this client may be proneto play out, and therefore be better prepared to respond to what thisparticular client is likely to present in treatment. In this way theycan better “see” what is going on between them and “hear” whatthe 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’mfeeling that way, too. Why do I get it now, and not then when she’ssaying it?!”).

In sum, working hypotheses go far in helping trainees makesense of their own experience in the hour and better grasp what istranspiring in their interpersonal process as it is occurring. Whentrainees find themselves reacting toward the client in unwantedways, such as feeling bored, discouraged, argumentative, and soforth, 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 goodtime to consult with a supervisor about process comments theymay want to venture, in order to begin exploring their subjectivereactions and working hypotheses with the client. Trainees cannotattempt process-oriented interventions without active guidancefrom 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 particularclient, they will find how helpful it is when they can link aspectsof the problem the client is talking about with others to theircurrent interaction—and begin changing this in their relationshipfirst.

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 ofdiscourse: T: May I break the social rules for a minute and askabout 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 myselfwondering if . . .), invite collaboration (e.g., “What do youthink?”), and provide these types of transition comments. Thesecontextual remarks help clients understand the therapist’s goodintentions, as they help clients shift from surface conversation to amore straightforward approach that invites deeper personal en-gagement. Rather than being threatened by this invitation, mostclients will welcome and be reassured by this bid to talk aboutwhat’s really wrong. All agree—these present-centered interven-tions that bring a greater level of engagement and intensity are themost anxiety-arousing for new therapists to adopt (Hill, 2009). Touse the process dimension effectively, instructors need to helptrainees do two things. First, they must balance the challenge ofmetacommunication with being supportive and protective of cli-ents’ self-esteem (Kiesler, 1996). Process comments, like anyother interventions, can be made in blunt, accusatory, or otherwiseineffective ways. Warmth, tact, curiosity, and a sense of humor canall go a long way toward making every intervention more effec-tive. Second, trainees can check in with their clients and talk aboutthe process intervention they just made: (T: How was it for youwhen I said that? I know people don’t usually speak so directlyabout what’s going on between them). In the initial session, weeducate clients about the treatment process by explaining that wewill try to help by speaking forthrightly and, in turn, we invitethem to speak up and express any concerns about us or treatmentdirectly. Then, we also inquire, “How would it be for you to talkwith 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 wantto jump in with process comments in a spontaneous or cavaliermanner. They want to be thoughtful about when and how they usethese powerful interventions, and always consider the possibilitythat their own observations or reactions may reflect more abouttheir own countertransference than it does about the client or theirinteraction. As a rule of thumb, experienced therapists usually waitto comment until they have seen an interaction occur two or threetimes. When in doubt about whether an observation has more to dowith the therapist or the client, it is best to wait, gather additionalobservations, and consult a supervisor before raising the issue withthe client. Again, all process comments are simply observations—offered tentatively, as possibilities for mutual clarification, not astruth 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.

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

340 TEYBER AND TEYBER

By looking honestly at their own contribution to problems ormisunderstandings, trainees facilitate an egalitarian relationshipthat holds genuine meaning for both. However, this increasingmutuality may activate trainees’ own personal problems or coun-tertransference at times (Yalom & Leszcz, 2005). In order to workrelationally, however, trainees need to relinquish hierarchical con-trol over the relationship, which can arouse anxiety for traineeswho need to be the authority or personally distanced in the role ofexpert. Additionally, trainees may be concerned that this genuineresponsiveness, emotional presence, or egalitarian stance will leadto a loss of appropriate therapeutic boundaries and result in over-involvement or acting out. One of the most important functions ofsupervision is to help trainees track this interpersonal process andrecognize when their own countertransference is prompting themto 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 alwayssusceptible to countertransference, and explore this with theirsupervisors, 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 challengingor exposing way. Trainees do not want to be confrontational just asmost clients do not want to be confronted. However, a processcomment, if used sensitively, seeks to communicate forthrightlyyet empathically and without blame or disrespect. Instructors helptrainees by clarifying that if they think the process comment theyare considering making is going to lead the client feel confrontedor blamed, don’t make it. Instead, trainees can wait for anothertime that feels better or, better yet, (with Use-of-Self) make adifferent process comment and talk with the client concerning theirreservations about sharing this observation: T: There’s somethingI’m thinking about right now, but I’m feeling unsure about ad-dressing it with you. I’m concerned you might misunderstand mygood intentions, and feel criticized or blamed, which I certainlydon’t want. May I ask for permission to speak frankly with you?

The goal with process comments, as with relationally orientedtherapies in general, is to create a new and reparative relationshipfor clients where it’s safe to talk about their distress and whatevermatters most to them—which includes how understanding andchanging what’s going on between “you and me” is often the bestway to begin changing what’s wrong with others.

References

Binder, J., & Strupp, H. (1997). “Negative process”: A recurrently discov-ered and underestimated facet of therapeutic process and outcome in theindividual psychotherapy of adults. Clinical Psychology: Science andPractice, 4, 121–139. doi:10.1111/j.1468-2850.1997.tb00105.x

Callahan, J., & Hynan, M. (2005). Models of psychotherapy outcome: Arethey applicable in training clinics? Psychological Services, 2, 65–69.doi:10.1037/1541-1559.2.1.65

Castonguay, L. G., & Hill, C. E. (Eds.). (2012). Transformation in psy-chotherapy: Corrective experiences across cognitive behavioral, hu-manistic, and psychodynamic approaches. Washington, DC: AmericanPsychological Association. doi:10.1037/13747-000

Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation,mentalization, and the development of the self. New York, NY: OtherPress.

Goldfried. (2006). Cognitive-affect-relational-behavior therapy. In G.Stricker & J. Gold (Eds.), A casebook of psychotherapy integration.Washington, DC: American Psychological Association.

Greenberg, L. (2002). Emotion-focused therapy: Coaching clients to workthrough their feelings. Washington, DC: American Psychological Asso-ciation. doi:10.1037/10447-000

Hill, C. (2009). Helping Skills: Facilitating exploration, insight, and action(3rd ed.). Washington, DC: American Psychological Association.

Hill, C. E., Thompson, B. J., Cogar, M. M., & Denman, D. W. (1993).Beneath the surface of long-term therapy: Client and therapist report oftheir own and each other’s covert processes. Journal of CounselingPsychology, 40, 278–287. doi:10.1037/0022-0167.40.3.278

Johnson, B., Taylor, E., D’elia, J., Tzanetos, T., Rhodes, R., & Geller, J. D.(1995). The emotional consequence of therapeutic misunderstandings.Psychotherapy Bulletin, 30, 139–149.

Kiesler, D. J. (1996). Contemporary interpersonal theory and research:Personality, psychopathology, and psychotherapy. New York, NY:Wiley.

Kiesler, D., & Van Denburg, T. (1993). Therapeutic impact disclosure: Alast taboo in psychoanalytic theory and practice. Clinical Psychologyand Psychotherapy, 1, 3–13. doi:10.1002/cpp.5640010103

Miller, W. R., Benefield, R., & Tonigan, J. (1993). Enhancing motivationfor change in problem with drinking: A controlled comparison of twotherapist styles. Journal of Consulting and Clinical Psychology, 61,455–461.

Mitchell, S. (1988). Relational concepts in psychoanalysis. Cambridge,MA: Harvard University Press.

Norcross, J. C. (2002). Psychotherapy relationships that work: Therapistcontributions and responsiveness to patients. New York, NY: OxfordUniversity Press.

Safran, J., Muran, J. C., & Proskurov, B. (2009). Alliance, negotiation, andrupture resolution. In R. A. Levy & J. S. Ablon (Eds.), Handbook ofevidence-based psychodynamic psychotherapy. New York, NY: Hu-mana Press. doi:10.1007/978-1-59745-444-5_9

Teyber, E., & McClure, F. (2000). Therapist variables. In C. R. Snyder &R. E. Ingram (Eds.), Handbook of psychological change: Psychotherapyprocesses and practices for the 21st century. New York, NY: Wiley.

Teyber, E., & McClure, F. (2011). Interpersonal process in therapy: Anintegrative model (6th ed.). Belmont, CA: Brooks/Cole.

Yalom, I., & Leszcz, M. (2005). The theory and practice of group psy-chotherapy (5th ed.). New York, NY: Basic Books.

Received February 25, 2014Accepted February 28, 2014 �

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

341TEYBER-PROCESS