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Therapist Interpretations and Client Processes inThree Therapeutic Modalities: Implications forPsychotherapy Integration

Nicola GazzolaUniversity of Ottawa

Anastassios StalikasPanteion University of Social Sciences

This research investigated therapist interpretations and subsequent client ac-tions in 3 therapeutic modalitiesclient-centered therapy, gestalt/existentialtherapies, and rationalemotive behavior therapyby employing the coding

system of the consensual qualitative research method (C. E. Hill, B. J.Thompson, & N. E. Williams, 1997). By allowing conceptual categories toemerge from these qualitatively analyzed data, the authors found that eachapproach had its own specific pattern of interpretation content as well as

style of delivering the interpretations. Client reactions to interpretations weremostly positive. The results suggest that interpretation is a common thera-

peutic element and that different therapies nonetheless accentuate differentaspects of interpretation. Implications for psychotherapy integration are of-

fered, and the findings are discussed with reference to theory and clinicalpractice.

The common factors perspective searches for fundamental similaritiesacross therapies (Arkowitz, 1997) and suggests that the effectiveness ofpsychotherapy is contingent on factors other than theoretical orientation(Ahn & Wampold, 2001; Hubble, Duncan, & Miller, 1999). Although stud-

Nicola Gazzola, Faculty of Education, University of Ottawa, Ottawa, Ontario, Canada;Anastassios Stalikas, Department of Psychology, Panteion University of Social Sciences, Athens,Greece.

Parts of the data contained in this article were presented at the 109th Annual Conventionof the American Psychological Association, San Francisco, August 2001.

Correspondence concerning this article should be addressed to Nicola Gazzola, Facultyof Education, University of Ottawa, Ottawa, Ontario K1N 6N5, Canada. E-mail:

[email protected]

397Journal of Psychotherapy Integration Copyright 2004 by the Educational Publishing Foundation

2004, Vol. 14, No. 4, 397418 1053-0479/04 /$12.00 DOI: 10.103 7/1053-0479.14.4.397


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ies have estimated that relationship factors have more predictive powerthan specific techniques (Assay & Lambert, 1999; Greenberg, 1994; Lam-bert, 1989), Coady (1991) cautioned that it is premature to conclude thatspecific interventions are unimportant(p. 258), and Henry, Schacht, andStrupp (1986) suggested that separating techniques and relationship factorscan create a misleading dichotomy. Therapist interpretation is a techniquethat has attracted attention from different therapeutic schools.

A therapist interpretation is a proposition that (a) goes beyond whatthe client overtly recognizes; (b) may take several forms, such as interpre-tation of defenses, transference, and explanation of feelings and behavior;and (c) adds something qualitatively different to clientsverbalizations andoften presents clients with new meanings or perspectives (Friedlander,1982). Implicit in this definition is the element of an alternative frame of

reference common to many definitions appearing in the psychotherapyliterature (Clark, 1995). The use of a pantheoretical definition of interpre-tation makes it possible to examine how interpretation is used across dif-ferent schools of psychotherapy.

It is important to examine the role of interpretation and its relation tothe occurrence of in-session therapeutic phenomena for several reasons.First, psychotherapists often use this intervention either explicitly or im-plicitly, and it has been hypothesized as a common factor across differenttherapeutic approaches (Claiborn, 1982; Frank, 1982; Garfield, 1989; Wal-born, 1996). Although it is extensively studied in psychodynamic schools oftherapy, it is a technique that is employed but not well understood in thenondynamic therapies. It is therefore important to understand how it isused as well as how it could be improved.

Second, it is important to deepen our understanding of the psycho-therapeutic change process. Garfield and Kurtz (1977) found that almosthalf of the clinicians they surveyed use whatever works best for theclient, and, with an ascending trend toward eclecticism (Fitzgerald & Osi-pow, 1986; Norcross & Newman, 1992), it is important to examine thera-peutic ingredients that facilitate client change. Interpretation has beenviewed as the central technique for producing self-knowledge and change(Hill, Thompson, & Mahalik, 1989, p. 284), and it is consistently associatedwith good outcome, rated as one of the most effective counselor techniquesby both clients and therapists (Elliott, Barker, Caskey, & Pistrang, 1982;Hill, 1989) as well as by objective observers (Elliott, 1985; Gazzola, Iwak-abe, & Stalikas, 2003; Gazzola & Stalikas, 1997). However, researchershave yet to understand the effects of interpretations on the moment-to-moment process of therapy in nondynamic schools of therapy.

Third, interpretation is still viewed more as a theoretical construct thanas a research variable in nondynamic schools. Within the psychodynamicschools, the value of different types of interpretations has been outlined,

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but the active ingredients of interpretation have not been fully explored. Innondynamic schools there is even greater ambiguity regarding interpreta-tions effectiveness, given that the research emphasis in these approacheshas been on variables other than interpretation. Interpretation in nonpsy-chodynamic approaches has not been systematically investigated, espe-cially in relation to in-session outcome or progress.

Trends in psychotherapy research are shifting from a macrolevel, mul-titheoretical perspective (e.g., psychodynamic, cognitive, humanistic) tomore microlevel analyses of what works in different conditions (Lambert,Garfield, & Bergin, 2004). This shift emphasizes a common factors ap-proach according to which it is important to identify factors that have aunifying potential, to build a therapeutic armamentarium that cuts acrosstherapeutic systems. By emphasizing what the psychotherapies share

rather than what separates them, common change principles provide ameeting ground for proponents of different schools, thereby promoting amore open, less doctrinaire stance (Messer & Warren, 1995, p. 222).

HOW DO THE MAJOR THERAPEUTIC MODALITIESREGARD INTERPRETATIONS?

The objective of this study is to describe the use of interpretations andsubsequent client processes in three mainstream therapeutic modalities:client-centered therapy (CCT), gestalt/existential therapies (GT), and ra-tionalemotive behavior therapy (REBT). We believe that if interpretationis common across therapeutic modalities, we must describe interpretations

in schools of therapy in which they are least expected as well as in thoseschools that commonly employ interpretive techniques (e.g., REBT).Whereas psychodynamic schools of therapy consider interpretation to bethe main therapeutic tool to effect change, CCT views interpretations as ahindrance to the psychotherapeutic process. In CCT, interpretations areviewed as external and explanatory, with the potential to do more harmthan good because the interpretive therapist introduces an external frameof reference. Interpreting communicates that the therapist is more knowl-edgeable than the client and can offer explanations regarding the clientsbehaviors, thoughts, feelings, and wishes. Instead, therapists following aCCT approach are encouraged to engage in a moment-to-moment trackingof the clients processes (Rogers, 1959). If the therapist provides a safeatmosphere, clients will become self-aware whenencouraged to identifyand symbolize their inner experiences for themselves, rather than havingthe therapist offer symbols to them to help them make sense of theirexperience (Greenberg & Rice, 1997, p. 104).

GT is grounded in the same underlying principles as CCT. According

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to GT, therapy is discovery oriented, and it is the clients who must discoverthe truth for themselves through exploring their inner experiences, withawareness regarded as the royal road to cure(Greenberg & Rice, 1997,p. 105). According to GT, clients must develop their own meanings ratherthan have meanings interpreted for them. GT is a phenomenological ap-proach in which therapists describe what they perceive without interpre-tation and attempt to give equal significance to all aspects of what is seen,heard, or felt (Clarkson & Mackewn, 1993) so that meaning emerges fromthe client. Interpretations, viewed as explanatory, are not to be used by theGT therapist. The therapist should use exercises, confrontations, and ques-tions to help the client become self-aware and discuss the past only to bringabout awareness in the present or to resolve unfinished business so that theclient can attend to the present.

Although very little has been articulated in REBT literature regardingthe use of interpretation in therapy, Ellis (1968) stated that the REBTtherapist employs interpretation with an emphasis on philosophical issuesrather than on explanatory ones. The REBT therapist interprets directlyrather than cautiously and is theory guided. Ellis is highly didactic and hasstated that he interprets right from the first session. The interpretations arephrased in the form of questions rather than declarative statements so thatpatients can learn to question their own thinking. Further, Ellis makes thesame interpretation repeatedly. The aim is to show the clients how theycreate and maintain their ownupsetness(Ellis, 1968, p. 237). Ellis (1989)agreed with the use of the main therapeutic tool of psychoanalysis, inter-pretation, and considered its useas cognitive as any therapist could pos-sibly be (p. 7).

IS INTERPRETATION COMMON ACROSS PSYCHOTHERAPIES?

Theoretical differences may represent profoundly divergent views ofreality and have different treatment implications, but a diversity of theo-retical viewpoints may reflect differences in labels applied to describe basicphenomena (Beutler & Guest, 1989). Whether one emphasizes interpre-tation of unconscious conflicts, distorted perceptions, or irrational beliefs,the patient is being given an explanation for his or her behavior(Garfield,1992, p. 187). Garfield argued that the emergence of cognitivebehaviortherapy is an example of how explanatory concepts are being incorporatedinto behavioral approaches. It seems that providing an alternative frame-work to the client is an act that is labeled differently by therapists(Garfield, 1992; Hammer, 1968; Walborn, 1996), but they may be describ-ing different aspects of the same phenomenon. The view that similar con-



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cepts are labeled differently across theoretical approaches lends itself wellto efforts of psychotherapy integration.Despite the fact that a majority of practitioners describe their approach

as eclectic, it is difficult to provide systematic research data on eclecticismbecause of the uniqueness of a given approach and variation betweentherapists (Garfield, 1992). An understanding of how a given intervention,such as interpretation, operates within a system under the theoreticalguidelines of that approach can ground the argument that interpretation iscommon to most therapeutic modalities. Therefore, even though mosttherapists practice some form of eclecticism, their choice of intervention isbest aided by an understanding of how that intervention is applied withina given theory.

The effects of interpretations on client change have been extensively

studied within a psychodynamic framework, but in nondynamic therapiesresearch studies on interpretation are scarce, and the notion that interpre-tation may constitute a common therapeutic element across psychothera-pies has not received empirical attention to date. With the objective ofdescribing therapist interpretations and client reactions to interpretations,the research questions for the present study are as follows: (a) What are thedifferent types of interpretations used in CCT, GT, and REBT? (b) Howare interpretations delivered in each approach? (c) What are the clientactions following interpretations (i.e., what does the client do after hearingthe interpretation?)

METHOD

The method employed in this investigation was a variation of the cod-ing system of the consensual qualitative research method developed byHill, Thompson, and Williams (1997). This method was chosen because itis compatible with process research in that it (a) simplifies a large amountof information without losing richness, (b) allows for the examination ofseparate categories of interest, and (c) allows for categories of data to beeasily charted, thus facilitating comparisons across cases (see Gelso, Hill,Mohr, Rochlen, & Zack, 1999; Ladany, Constantine, Miller, Erickson, &Muse-Burke, 2000).

Multiple clinical judges introduced several clinical points of view, and,as judges arrived at a consensus regarding every clinical judgment, poten-tial biases of a single perspective were reduced (Hill et al., 1997). Biasesand unwarranted inferences are more easily monitored, and the biases ofany one person may be circumvented, through the use of multiple judges.Further, researcherscould easily miss crucial nuances of the data because



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their biases or expectations might influence their understanding of thedata (Hill et al., 1997, p. 523).

Sample

A total of 12 sessions were used in this study, 4 per therapeutic mo-dality. In REBT, 4 sessions conducted by Albert Ellis were included, andin CCT only sessions conducted by Carl Rogers composed the sample.Because of the lack of availability of 4 sessions by the same therapist in GT,each of the 4 sessions was conducted by one of four different therapists.Once the 4 sessions in each approach were selected, 4 interpretations ineach of the 12 sessions were randomly selected, totaling 48 different inter-

pretations (16 segments per school).The CCT sample comprised the following sessions: Rogers and Miss

Munn, Rogers and Mrs. P. S., Rogers and Kathy, and Rogers and Gloria.The REBT sessions were as follows: Ellis and Elkli, Ellis and Gloria, Ellis andJane Doe, and Ellis and Orville. The GT sample comprised the followingsessions: Perls and Gloria, Sagan and a young man, Levitsky and Miss L., andJourard and a young man. These were all initial or early sessions.

Clinical Judges

Six judges, three men and three women, were divided into two groups

of three. These judges were graduate students in a counseling psychologyprogram at a large Canadian university. The six judges were divided intotwo primary research teams of three and were responsible for generatingqualitative descriptions of the samples.

Procedure

Consistent with a discovery-oriented approach (Mahrer, 1988), judgeswere given the tapes and transcripts of sessions along with the selectedsegments containing interpretations. Each group of three judges was givenone session (audio tape, transcript, and instances of interpretation con-tained in that session) at a time and asked to describe the segment in asmuch detail as possible using four research questions as general guidelines.Each question served the role of a domain, or overarching theme, for theemerging categories. The judges worked individually on the questions, andthen both groups of judges met to discuss the results in a consensus meet-



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ing. After core ideas were agreed on, Nicola Gazzola met with an auditor,who verified the categories (see Figure 1).Domainsare conceptual headings that encompass several categories.

Judges were given the research questions along with the previously codedinterpretations and asked to be as descriptive as possible in answeringthem.Core ideasare succinct terms or phrases that capture the essence ofthe answers to the research questions. Once the clinical judges completedthe task of answering the research questions individually, they submittedtheir descriptions to N. Gazzola, who collected and compiled the data. Thegroup then met to discuss each event described, with the aim of generatingdescriptions of the process following interpretations as well as workinghypotheses for clinical uses of interpretation. The consensus meetings wereused to generate core ideas. All material summarized by N. Gazzola was

Figure 1.Process steps in the coding of data.



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discussed by the research team (all six clinical judges) until consensus wasreached for every core idea.Once the core ideas were outlined within each domain, N. Gazzola

charted the data and presented them to an auditor (A. Stalikas), whoensured that the core ideas were reflective of the raw data. Data collectionand analysis was an iterative process, as the charted data were refinedcontinually as new categories emerged. Every time a new core idea wasdescribed, all previously charted sessions were once again verified to assesswhether they contained the category.

RESULTS

The results generated are descriptions of processes and are presentedin the form of tables, which are arranged by research question and allow forcomparisons within and across the three approaches studied. Each categorythat the clinical judges described is illustrated with the use of verbatimexamples from the sessions. The cross-analysis tables list all the categoriesthat were generated by the clinical judges and the endorsement of eachcategory in each of the three schools.

Content of Therapist Interpretations

Content refers to the topic of the interpretation and answers the ques-

tion,What is the therapist interpreting?The judges discovered five cat-egories of interpretation content (see Table 1).

Behaviors or Actions

The first category, interpretation of client behaviors, occurred infre-quently in all three therapies and was divided into three subtypes: nonver-bal behavior, generalizing from one behavior to more behaviors, and rea-sons or causes for client behaviors. Interpretation of nonverbal behaviorrefers to pointing out an observed behavior in the session and inferring itsmeaning. For instance, in a session of CCT, Rogers told the client, I thinkyour eyes tell me youre feeling a risk right now,in describing the clientsfear of opening up in relationships. Generalization from a specific in-session behavior to a way of being outside of therapy can be observed inthe following CCT interpretation: Youre very easy to run away fromyourself, you know.A third subtype of interpretation of behavior refers to



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reasons for client actions. For instance, in a session of GT, the therapiststated,Oh, I think the other way around. If you play dumb and stupid, youforce me to be more explicit,in attempting to show the client the reasonthat she is not assertive with the therapist.

Defenses

A second category found by the judges was interpretation of clientdefenses. The following example of this type of interpretation comes froma session of GT:You have, umm, suggested to me on many, many occasionsthat I do this or that out of strategic considerations. In as much as I know thatI dont work that way, I therefore know that its your projection.

Interpretation of Feeling

Interpretation of feeling was divided into four subtypes. The first ofthese is interpretation of the causes of the client s feelings. This type ofinterpretation occurred frequently in REBT and infrequently in both CCTand GT. For example, in responding to a client who reported feelinglowin a session of REBT, the therapist stated,

Table 1.Cross-Analysis of Content of Therapist Interpretations in CCT, REBT, and GT

Category

Endorsement of each category

CCT REBT GT

Behaviors/actions Variant Variant VariantIn-session nonverbal Variant Variant VariantGeneralizes Variant None VariantReasons None Variant Variant

Defenses Variant None TypicalFeelings General General Typical

Origin and causes Variant General VariantToward therapist Variant None VariantToward others Variant Variant VariantSelf Typical Typical Variant

Needs Variant Variant VariantThoughts/beliefs Variant Variant None

About others Variant None None

Origin/causes None Variant NoneNote. CCT, REBT, and GT are each composed of 16 segments. None indicates that thecategory did not occur in a given school;Variantindicates that the category occurred between1 and 5 times, inclusively, in a given school; Typicalindicates that the category occurredbetween 6 and 10 times, inclusively, in a given school; General indicates that the categoryoccurred between 11 and 16 times, inclusively, in a given school. CCT client-centeredtherapy; REBT rationalemotive behavior therapy; GT gestalt/existential therapy.



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You felt low because youre saying,Looks are sacred, Im not as good looking asI should be, ergo, Im no good, and then you feel low. . . . Its the belief in thesacredness of looks that makes you feel low.

The second subtype of interpretation of feeling refers to feelings towardthe therapist. In a GT session, the client was apprehensive and appearedguarded with the therapist. The therapist interpreted the clients feelings to-ward him and pointed out a possible transference. The therapist stated,

You giggle like a little girl as if you don t have the right to disagreeand if youdont give yourself that right, if you have a picture of yourself as a little girl vis-a -visme, wouldnt that have enormous implications for everything that happens here?Im, Im not another person who happens to be a man, I m a daddy figure therapistand youre a little girl, and so what are we doing here?

Interpretations about the clients feelings toward others occurred in-frequently in all three therapies. An example of this subtype of interpre-tation was observed in a CCT session in which the client was describing herfeelings toward her mother. The therapist stated, I guess youre saying,Ireally dont like the weakness in my mother.

The final subtype of interpretation of feeling that emerged was aninterpretation of clients feelings toward themselves. In a session of CCT,the client was experiencing fear regarding her diagnosis for a physicalcondition, and the therapist stated, Is this what youre saying? Couldanyone be with you in fear or loneliness like that? It really cuts so deep.

Needs

A fourth category of interpretation content referred to client needsand occurred infrequently in all three therapies. In a session of REBT, thetherapist interpreted to the client that the reason the client puts othersdown is because he has a need to feel better about himself. Another ex-ample of interpretation of needs comes from a CCT session in which thetherapist interpreted the clients need for acceptance:What you want is toseem perfect . . . and you want to seem to be a good mother even if youractual feelings differ from that.

Thoughts

The fifth category of content of therapist interpretation that the judgesfound focused on thoughts and beliefs and occurred infrequently in allthree approaches. Two subtypes emerged, one focused on thoughts about



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others, and the other focused on the origin or causes of the thoughts.Interpretations about the thoughts or beliefs about others occurred infre-quently in CCT and never in REBT nor in GT. In an example of this kindof interpretation from a session of CCT, the therapist stated, Sounds asthough perhaps this is what youre saying, that when you really think backand try to understand your childhood, then you feel,Gosh, Im not so sureabout my father. He surely seemed to be harsh.

The second subtype of interpretation of thoughts, focused on the ori-gins or causes of beliefs, was unique to REBT. This involved explaining tothe client the reasons for his or her beliefs. For instance, in a session ofREBT, the therapist was interpreting why the client values physical ap-pearance so much and makes it sacred. He stated, I think its a matter ofinnate, what youre thinking. But the fact that you picked that is partially

cultural. In some other society you wouldnt have picked that, youd havepicked brains, or marks, or something else as all important.

We observed a continuum from CCT to GT to REBT in terms of theproximity of the content of interpretation to the client data. In CCT, thetherapist interpreted content that was experience nearfor the clients, andmost interpretations were placed in the context of the therapist trying tounderstand the material from the clients point of view. In REBT, thetherapist often linked the clients verbalizations to the REBT model. Thatis, clientsbehaviors, feelings, and thoughts were explained through REBTtheory. In other words, the therapist tried to have the client understand thematerial from the point of view of REBT theory. GT therapists variedbetween the two approaches. An example of anexperience-farinterpreta-tion from an REBT session is,

Youll never find that out, and I think it s a matter of innate, what youre thinking.But the fact that you picked that is partially cultural. In some other society youwouldnt have picked that, youd have picked something else, . . . Why is it sacredthat I be physically attractive in order to go to class?

The closeness of the content of interpretation to the client data seemed tobe therapy specific. It was atypical for the CCT therapist to interpretcontent that was far from client verbalization and, conversely, for theREBT therapist not to do so. The GT therapist seemed to alternate be-tween experience-near and experience-far interpretations.

Style of Delivery of Therapist Interpretations

The second research question was concerned with how the therapistdelivered the interpretations. This question is independent of interpreta-tion content, focusing instead on the manner, style, and form of the inter-



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pretation. The judges found five categories of therapist style of interpre-tations (see Table 2).

Tense Used

It was common for CCT, REBT, and GT therapists to use the presenttense when delivering an interpretation. Judges described this asworkingin the here and now,and it involves making interpretations using feelings,thoughts, and behaviors as they occur in the session. At times the therapistused a past tense and a present tense in the same interpretation, but the judgesagreed that the emphasis was usually in the immediate moment. An exampleof an interpretation delivered in the here and now comes from a CCT sessionin which the therapist interpreted the clients feelings in the present, Youknow I just dont have a chance to be a person. Everybodys all ready to bemefor me. In both CCT and GT, judges found an infrequent occurrence ofthere-and-theninterpretations, which focused on a past feeling.

Manner of Delivery

Two subtypes of delivery were found. The first was a presentation ofthe interpretation as factual, stated in absolute terms. In this type, inter-pretations were presented as if they were fact. Both REBT and GT invari-ably used this approach to deliver interpretations, whereas in CCT this was

Table 2.Cross-Analysis of Form of Therapist Interpretations in CCT, REBT, and GT

CategoryEndorsement of categories

CCT REBT GT

TenseHere and now (immediacy) General General GeneralThere and then Variant None Variant

DeliveryFactual/absolute Variant General GeneralTentative General None Variant

ToneChallenging/directive Variant General TypicalSupportive/caring General Variant Typical

PronounFirst person (I) Typical Typical NoneSecond person (you) Typical Typical General

Questioning Variant Typical Variant

Note. CCT, REBT, and GT are each composed of 16 segments. None indicates that thecategory did not occur in a given school;Variantindicates that the category occurred between1 and 5 times, inclusively, in a given school; Typicalindicates that the category occurredbetween 6 and 10 times, inclusively, in a given school; General indicates that the categoryoccurred between 11 and 16 times, inclusively, in a given school. CCT client-centeredtherapy; REBT rationalemotive behavior therapy; GT gestalt/existential therapy.



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done infrequently. An example of this type of delivery was observed in GTwhen the therapist stated, I think youre angry at me for daring to en-courage you to explore along certain lines.In REBT, the therapist oftenpoints out the clientscatastrophizingand presents the interpretation asfacts. For example,You really mean your chances would be reduced . . .you see youre generalizing there.One example in CCT had the therapistinterpreting in the following way: And this morning has been an exampleof the fact that youre not going to go so fast that you crash.This was anatypical, or variant, way of delivering interpretations in CCT, in which thestatement is presented in absolute terms or as fact.

The other subtype of delivery was considered tentative and con-trasted with the absolute form. In tentative interpretations, the therapistused terms such as maybe and Is this what youre saying? A tentative

approach was common in CCT interpretations and occurred infrequentlyin GT. Tentative interpretations were not observed in REBT. One ex-ample of a tentatively delivered interpretation was observed in CCT: Thisis your concern, I guess, umm, Im sure this will sound evasive to you, butit seems to me that perhaps the person youre not being fully honest withis you.Here the judges observed that the therapist used words such asIguessand perhaps,and often the therapist would check with the client byasking,Is that part of it?This type of delivery was characteristic of CCTinterpretations and infrequent in GT.

Therapist Tone

A third category that the judges found referred to the therapiststonewhen delivering the interpretations and included the manner in which thetherapist spoke or the tone of voice used. Two subtypes of tone were found.The first is a challenging and directive tone, a general occurrence in REBTand infrequent in CCT. GT used this tone in a moderate degree. Challengingtone also encompasses a confrontational style, and when interpretations weredelivered in this way, judges found that therapists tried to provoke or chal-lenge the clients. In contrast, a second subtype found was termed supportive/caringand was common in CCT. Here the therapist used a caring, soft voice,and if the interpretation was rejected, the therapist corrected himself ratherthan the client. Other terms that judges used to describe this type of tone wererespectful of the clientandmatching the clients voice.

Type of Pronoun Used

A fourth category to emerge was the type of pronoun used by thetherapist in delivering the interpretations. The first type was using first



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person for the client. REBT and CCT used this to a moderate degree, andGT therapists never used this style. Using first person pronoun was de-scribed by judges as usingIlanguageand speaking as if the therapist wasthe client (i.e., using the voice of the client). For example, You know, I

just dont have a chance to be a person. Everybodys all ready to be me forme. In this example the therapist speaks as if he were the client.

The second type of pronoun used was described by the judges as youlanguage or talking to the client and was a general occurrence in GT.This form of pronoun was used moderately in CCT and REBT. Interven-tions in this category are phrased as you think or you feel.

Use of Questions

A final category that the judges found is the use of questions in phras-ing the interpretations. This type of questioning was termedSocraticorteaching by questioning. Judges described this as asking a question towhich the answer was known to the therapist and often also to the client.This was found to occur moderately in REBT sessions and infrequently inCCT and GT. An example of this was observed in REBT as follows:Now,whats the answer, why is it sacred that I be physically attractive in orderto go to class?The judges described this as the therapist trying to let theclient come up with the answer that he already knows. The questionseemed to serve the function of teaching the clients to challenge theirbeliefs and to allow for deeper understanding of where their distress comesfrom.

Client Actions Subsequent to Interpretations

Five categories of client actions were found by the clinical judges (seeTable 3).

Endorsement of the Interpretation

In GT, the endorsement of the interpretation by the client was equallydivided between accepted and rejected interpretations. In both CCT andREBT the clients generally accepted the interpretations. Accepting theinterpretation could be as straightforward as the client saying, Yes, thatsexactly it,or, Thats right,or more subtle, in that the client continuedfrom the therapists interpretation. For example, in a session of REBT, the



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client responded,Yeah, yeah, so if I have that kind of feeling, just to keepmaking myself aware that its not a sacred characteristic, necessity.Herethe client accepts the interpretation that she is making herself feel low byovervaluing her appearance. In the following example from CCT, thetherapist made an interpretation that focused on the clients feelings to-ward her mother. The clients response indicated that she accepted theinterpretation and continued her disclosure: And it came out in otherways, when we were in this country, and my grandmother was no longer

alive. My mother seemed always to feel that she had to be doing some-thing.Similarly, when interpretations were rejected, they were either re-jected clearly, such as, No, I dont feel that, or mildly disagreed with,such as a misunderstanding that was later clarified.

Clarification

A second category found by judges was clarification. In this category,the client felt misunderstood and either clarified what he or she said pre-viously or resisted the interpretation. When clients explained themselves,they rejected the therapists interpretation or disagreed with part of it. Forinstance, in a session of CCT, the client response following an interpreta-tion was, Gee, I dont feel like Im saying that, no. That isnt what I feel,really. I want to approve of me always, but my actions won t let me. I wantto approve of me, I, I think.In this example, the client felt misunderstoodand restated what she wants. This was termed explaining self by the

Table 3.Cross-Analysis of Client Actions in Segments Following Therapist Interpretationsin CCT, REBT, and GT

Category

Endorsement of each category

CCT REBT GT

Endorsement of interpretationAccepts General General TypicalRejects Variant Variant Typical

ClarificationExplains self Variant Variant VariantResists/deflects Variant None Variant

Explores feelings/thoughts Typical Typical TypicalDiscloses information General Typical TypicalExpresses new understanding Variant Typical Typical

Note. CCT, REBT, and GT are each composed of 16 segments. None indicates that thecategory did not occur in a given school;Variantindicates that the category occurred between1 and 5 times, inclusively, in a given school; Typicalindicates that the category occurredbetween 6 and 10 times, inclusively, in a given school; General indicates that the categoryoccurred between 11 and 16 times, inclusively, in a given school. CCT client-centeredtherapy; REBT rationalemotive behavior therapy; GT gestalt/existential therapy.



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judges and occurred infrequently in all three approaches (variant occur-rence). The other type of clarification was resistance by the client. Here theclients changed the topic and seemed to not want to continue along thelines of the therapists interpretation. Following a therapist interpretationin CCT, the client responded, Those holes are hard on the eyes,referringto lights from the ceiling. In a session of GT, the therapist interpreted theclients feelings toward him as manipulative, to which she responded,Stopbeing gruffy,and went on to ask the therapist for clarification regardinghis interpretation of her behavior. In another session of GT, the clientbecame angry following an interpretation suggesting that she was not beingauthentic in the session and responded,I still resent that. Im not a phonywhen Im nervous.

Exploring Feelings and Thoughts

The third category of client actions that the judges found was exploringfeelings and thoughts, and it occurred with moderate frequency in all threeschools. For instance, in a GT session, the therapist interpreted that theclient was projecting her insecurities onto him. She paused for 30 s andstated,

Okay, the only thing that I can come up with at this point is that, umm, I, one of myanticipations had been before I came here, I felt, I felt real good on Saturday, I, I

just felt like I didnt want to leave and listening to the tape player on, there was areal richness in that, in that umm, interaction . . . and I thought okay, if this was sucha good session the next ones going to be having frustration in it.

The therapist reflected her statement, and then the client responded,Iguess . . . its my, the way I work and think with people. Here the clientexplored the nature of her feelings with the therapist and tried to under-stand why she anticipated frustration in the session. In another examplefrom a GT session, the therapist interpreted that the client has two extremereactions with people,Either far away in the corner or be so close that youmelt into one with the other person, and apparently you travel between thetwo extremes. The client responded,

I do. You know what Im thinking, when Im really hurt and upset with someoneand I want someone to love me, like my girlfriend will do it a little, and she ll comeup to hug me. I dont want it.

Self-Disclosure

This client response to interpretation occurred frequently in CCT andmoderately in both REBT and GT. This information was new and was



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judged significant by the clinical judges. For instance, in a CCT session, thetherapist interpreted the clients feelings toward others, and the clientresponded with information about her behavior that was new and seemedrelevant to her complaints. She responded,

Thats right, you know thats exactly it. Before therapy I would have definitelychosen the other area. Im going to get respect from them no matter what, even ifI have to lie . . . I want reassurance, I keep wanting these things.

Expressing New Understanding

In expressing new understanding, the client could be realizing some-thing new or coming to a new understanding based on the interpretation,at times making a link between events or feelings. This occurred moder-ately in both REBT and GT and infrequently in CCT. In a session ofREBT, the therapist interpreted the source of the clients anxiety as beingcreated by her self-talk, and the client seemed to gain a new understandingof her problem, stating, You know, you are absolutely right about onething. I feel like she must see it in a certain way . . . and then Im leadingmyself to failure.

DISCUSSION

The overarching goal of this study was to examine the utilization of

interpretation across different schools of nondynamic therapies and to ex-amine its role as a potential common therapeutic intervention. Through theidentification of common elements, better and more effective theories ofchange are made possible (Arkowitz, 1997). Three nondynamic therapieswere selected for the sample because of their diverse views regarding in-terpretation. CCT, REBT, and GT differ in their philosophical underpin-nings, articulate different theories of change, and, therefore, use interpre-tations differently. As an intervention, interpretation necessitates theintroduction of an alternative frame of reference, which is a concept thatseems to be theoretically incompatible with CCT and GT.

This study demonstrates that interpretations are employed in a quali-tatively different manner in each therapeutic approach. The interpretationswere delivered in a manner consistent with the theories employing theinterventions, and each approach focused on different content. The com-monality is that the interpretations provided clients with an alternativeframe of reference or an explanation. The notion ofassimilative integration(Messer, 1992) may be a viable heuristic in the conceptualization of inter-



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pretation as compatible within various theoretical orientations. Assimila-tive integration refers to a therapist incorporating (i.e., assimilating) apractice from another school while remaining strongly grounded in his orher own school (Messer, 1992). In this light, therapies that assimilate con-structs from other systems use them differently because their theoreticalfoundations are different. The current results demonstrate that interpreta-tion was used by the three approaches but that it was employed differentlyand, as Messer would argue, likely used to achieve different goals.

Arkowitz (1997) stated that not only is the imported techniquechanged so that it fits the theory, there is a possibility that the fundamentalapproach is also changed. In the current sample, interpretations were usedin a manner consistent with each therapists respective approach. Furtherresearch is needed to explore whether the fundamental therapeutic mo-

dality that imports interpretations may also change as a result of employingan intervention that appears to violate its theoretical assumptions.

The different approaches were relatively consistent with regard to theirprofessed methods of conducting therapy, yet they all used interpretations.An important point here is the compatibility of interpretation with inter-ventions theorized in respective schools. For instance, in CCT the therapistwas described as caring and respectful while delivering interpretations.Thus, interpretations were embedded in a supportive, caring, and respect-ful relationship in CCT. Similarly, REBT interpretations were embeddedin a directive and educative approach. The GT interpretations were deliv-ered in a manner consistent with GTs theoretical position, encouraginggenuineness in the client and applying skillful frustration on the part of thetherapist. These results support the potential use of interpretation as an

intervention that can be assimilated into existing, well-grounded theories.The finding that interpretation is employed in equal frequencies acrossthree nondynamic therapeutic approaches is an important step toward theestablishment of interpretation as a common therapeutic factor.

The client reactions to interpretations were also diverse. Clients rarelyrejected the therapist interpretations; rather, they typically explored theirthoughts and feelings following interpretations. Interpretations were alsoassociated with clients disclosing information and expressing new under-standings. In psychodynamic therapies, interpretations are valued mostlybecause of their association with insight. However, as suggested by thisstudy, other valued client change processes follow interpretations. For ex-ample, the current findings show that clients explored feelings and dis-closed important information following interpretations. The use of inter-pretation to elicit these types of client responses has not been explored, asthe research has emphasized the importance of insight following interpre-tation. Future researchers may want to explore the relationship betweeninterpretations and various client reactions so that clinicians may employ



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interpretations with increased foresight regarding their potential effects. Itis also interesting to note that client reactions to interpretations were typi-cally positive; only rarely were the interpretations rejected. This finding iscontrary to CCTs and GTs theoretical positions on interpretation and isconsistent with the general research literature on interpretation, whichsuggests that it is a helpful intervention.

This study provides a lexicon of interpretation content and form innondynamic therapy. These findings must be replicated with a largersample and refined. Perhaps this could lead to a scale for classifying inter-pretations in nondynamic therapies similar to those in use in psychody-namic research on interpretations. These results suggest that interpretationis not a uniform construct in therapy. Treating all interpretations as equaloversimplifies them and fails to take into account the diversities of their

applications. The results of this research also suggest that interpretationsare associated with a diversity of responses. Future research may profit byexamining the different types (and style of delivery) of interpretations andtheir association with different client processes in nondynamic therapies.

Finally, it is important to transport the findings to other forms oftherapy. Garfield (1990) estimated that there are 400 types of therapy,which emphasizes the importance of identifying active ingredients. Thecurrent findings support the proposition that interpretation is a commonintervention in therapy. Using a definition of interpretation that enablescomparisons across different orientations is necessary in this endeavor, andreplication of these findings in different approaches is crucial in futureresearch. Further, linking interpretation with outcome is necessary if in-terpretation is to be truly considered a common therapist application

(Arkowitz, 1997).The results have clinical and training implications and suggest that

practitioners may move beyond the boundaries of their preferred approachwithout altering the fundamental framework that they employ. Despite thedifferent conceptualizations of interpretation at a theoretical level, therewas considerable overlap among the three approaches in this study at apractical level. This is consistent with Ablon and Jones (1999), who ob-served that the distinctiveness of therapeutic approaches is less pro-nounced at the level of practice than it is at the abstract, theoretical level.

There seems to be an increased acceptance of the cross-fertilization oftechnical aspects of therapy in an effort to improve practice. Lambert et al.(2004) noted that there is a shift in psychodynamic therapies that increas-ingly acknowledges the value of the therapeutic relationship in addition totechnical interventions such as interpretation. In a similar vein, Elliott,Greenberg, and Lietaer (2004) suggested that nondirective, humanistic ap-proaches can be enhanced through the integration of more directive tech-niques. In assimilating techniques from other approaches, practitioners can



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build an expansive armamentarium of psychotherapeutic tools that offersbetter clinical practice.The results of this study must be interpreted in light of its limitations.

Some concessions were made to obtain representative samples of sessionsof expert therapists practicing their professed therapeutic approaches, andthe sample was therefore limited to the availability of orthodox therapysessions. Of particular importance to this investigation is that we sampledmaster therapists who developed therapeutic approaches rather than ob-taining a large, random sample of therapists. We used only sessions withCarl Rogers for the CCT sample and sessions with Albert Ellis for theREBT sample. In the GT sample there were four different therapists, andboth gestalt and existential therapies were combined, making this the leastpure of the three approaches. Another limitation is related to the sim-

plification of the data structure (Elliott & Anderson, 1994). Process unitswere treated as equivalent, and we made no attempt to examine interpre-tations at different times. We recognize that interpretations may be re-ceived and processed differently by clients when the therapeutic relation-ship deepens and also that context may be important to consider. We alsorecognize that therapy is a dialectical process in which the participantsinfluence each other. We asked our research questions in a manner thatimplies that client responses are reactions to therapist interventions, andwe did not study how client actions may influence the therapists inter-vention.

Despite these limitations, we believe that this study makes a contribu-tion in describing the similarities and differences in how master therapistsformulate interpretations as well as in describing the various client reac-

tions to this intervention. Interpretations seem to be commonly employedinterventions across different therapeutic modalities, and they are associ-ated with several client responses that are considered therapeutic. Thefindings suggest that interpretations can be assimilated into an existingframework so that different therapies accentuate different aspects of thisintervention.

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