A qualitative investigation of eminent therapists' values within psychotherapy: Developing...

A Qualitative Investigation of Eminent Therapists’Values Within Psychotherapy: DevelopingIntegrative Principles for Moment-to-MomentPsychotherapy Practice

Daniel C. Williams and Heidi M. LevittUniversity of Memphis

Ample empirical research on values has demonstrated that clients’ valuestend to become increasingly like those of their therapist during therapy.There is little research, however, on how therapists negotiate value conflictsand the role of values in therapy. In order to better understand this process,14 expert psychotherapists from four major psychotherapy orientations wereinterviewed about their use of values in the psychotherapeutic change pro-cess. A grounded theory analysis was conducted leading to an integrativeunderstanding of how expert therapists from different orientations concep-tualize the relationship of values and change in therapy and how they workwith values in sessions. Based on this analysis, four transtheoretical princi-ples were generated that can be applied to training and practice and used toinform research on psychotherapy process and integration.

Keywords: qualitative research, values, psychotherapy integration, treatment principles

Originally developed as a scientific procedure aimed at understandingand changing human experience, many psychotherapists now believe psy-chotherapy to be inherently value laden (e.g., Bergin, 1980). Debates haveraged on whether psychotherapy might be properly considered as a processof value conversion (e.g., Bergin, 1991; Meehl, 1959). Indeed, studies haveshown that, through the course of therapy, clients’ values tend to becomeincreasingly like those of their therapists, and that therapists tend not to

Daniel C. Williams and Heidi M. Levitt, Psychology Department, University of Memphis.The authors would like to express their appreciation to Robert Neimeyer and Sara

Bridges for their thoughtful feedback on previous drafts of this manuscript in the form of thefirst author’s master’s thesis and would like to thank the therapists who donated their time asparticipants.

Correspondence concerning this article should be addressed to Daniel C. Williams,University of Memphis, Department of Psychology, 202 Psychology Building, Memphis, TN38152. E-mail: [email protected]

Journal of Psychotherapy Integration Copyright 2007 by the American Psychological Association2007, Vol. 17, No. 2, 159–184 1053-0479/07/$12.00 DOI: 10.1037/1053-0479.17.2.159

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consider clients to be improved until there is increased value similarity(e.g., Beutler, 1979; Kelly, 1990; Rosenthal, 1955; Tjeltviet, 1986). It is notonly beliefs about mental health that appear to be persuasive, but thera-pists’ personal and religious values have been found to influence clients aswell (Beutler, 1979; Kelly & Strupp, 1992). Interestingly, therapists’ valuesdo not appear to shift (Rosenthal, 1955; Tjeltveit, 1986), suggesting that theterm “value convergence” is inappropriate, as it suggests that both clients’and therapists’ values merge when only the clients’ values appear to shift(Tjeltveit, 1986).

What perhaps is most provocative is that therapists seem not to be inconscious control of this process of value conversion. According to Kelly(1990), “Therapists do not remain value free even when they intend to doso” (p. 171). Furthermore, it seems that even when therapists are aware ofthe value-laden nature of psychotherapy, they typically do not conceptu-alize their work in terms of values (Williams, 2004). Paul Meehl (1959)noted, “Suppose that the empirical research should show that. . .all thera-pists are crypto-missionaries. Such a finding would present us with a majorprofessional and ethical problem” (p. 257). This empirical evidence sug-gests that Meehl’s nightmare is in fact our reality. As Meehl noted, thisdevelopment has presented the discipline with serious ethical consider-ations about the danger of therapists abusing their power by imposing theirvalues on clients (e.g., American Psychological Association [APA], 2002).

LIMITATIONS WITH EXISTING VALUES RESEARCH

Rosenthal (1955) was the first to quantify the study of values inpsychotherapy. Since then, several instruments have been developed formeasuring values (e.g., Spiegel, 1982). The most commonly utilized mea-sure is the Rokeach Value Survey (RVS; 1973). In this section, we willreview several limitations to the understanding of values implicit in thecurrent literature on value changes in psychotherapy.

Value Atomization

The existing literature on values often has assumed that values areindependent, isolatable, and separate from each other (Levitt, Neimeyer,& Williams, 2005). The RVS research has exemplified this assumption(Rokeach, 1973), creating categories of values such as equality, justice,forgiveness, and honesty. This view has led to an understanding of valuechange as discrete and uninfluenced by other values.

160 Williams and Levitt

In the realm of counseling practice, Tjeltveit (1986, 1999) has proposedthat mental health values (e.g., a belief that depressive symptoms should bedecreased) can appropriately be influenced by therapists because thesevalues reflect their expertise and are the purpose of client consultation. Hisclaim, however, has been that therapists should refrain from influencingother unrelated values (e.g., religious beliefs). This atomization of valuesinto categories is an attempt to protect client autonomy by minimizing theeffect of what he sees as therapists’ extraneous values on the therapeuticprocess.

At the same time, other theorists have suggested that all values areultimately interconnected and “webbed” in nature, thus making themimpossible to isolate and understand independently of one another (Slife,Smith, & Burchfield, 2003; Slife, 2004; Walsh, 1995). As an alternateassumption, Walsh (1995) argues that values change according to differingcontexts and in relation to the relationship at hand, thus making themimpossible to comprehensively understand with context-less measures. Inaddition, Prilleltensky’s work (e.g., 1997) argues that psychology as a fieldtends to be so focused on values within an interpersonal context that rarelyis the political, social, or structural context acknowledged or challenged.Slife (2004) and Walsh (1995) recommend qualitative methods for a holis-tic approach to studying values.

Lack of Applicability

Although the RVS and other values measures are helpful in exploringhypotheses about changes in sets of values, they do not contexualizefindings about values within the moment-to-moment interactions of psy-chotherapy (Levitt et al., 2005). For example, the research findings fromKelly and Strupp (1992) that religious values are influential in therapy doesnot itself inform therapists about what to do with these values in session. Inother words, although the empirical literature has led to important infor-mation, it may not be as useful in developing innovative solutions to thisethical dilemma within the therapy session.

Putting the Cart Before the Horse

Additional problems also exist with the current literature. Levitt et al.(2005) argue that psychology’s natural science approach to empiricism hasoriented it toward formulating rule-like solutions to this dilemma. Forinstance, while some theorists assert that therapists should attempt to

161Therapists’ Values Within Psychotherapy

minimize or control their values (e.g., Tjeltveit, 1999), others suggest thattherapists should disclose their values to clients to initiate dialogues onvalues (Slife, 2004). These sets of rules are recommended as generalsuggestions to regulate therapists’ use of values prior to the development ofa complex understanding of value conversion. In contrast, principles couldbe developed by first asking therapists about their practice of therapy andthen developing a comprehensive understanding of how values are activelynegotiated within therapy sessions rather than beginning with a theoreticalfoundation.

STUDY OBJECTIVES AND DEVELOPMENT OF ANALTERNATIVE PARADIGM

Qualitative research is particularly well-suited for the exploration ofvalues within therapy. These methods are particularly adept at helpingresearchers understand complex intentional and implicit processes such asthose found in psychotherapy (Levitt & Rennie, 2004) and as such holdgreat applicability for therapy practice. They are uniquely suited to detect-ing the subtly shifting and evolving nature of values by understanding themas they relate to therapeutic interaction. Qualitative analysis also allowsinvestigators to circumvent the issue of intrapersonal atomism by assumingthat human experience is holistic, and inquiring about values in the contextof an individual’s broader meaning making processes (Slife, 2004). Thisarticle focuses on the experience of eminent therapists (see Goldfried,1980, for use of expert therapists for integrationism) from within the fieldas they describe negotiating values in sessions and may bring to lightstrategies and understandings that underlie these therapists’ work.

METHOD

Participants

Fourteen experts in the field of psychotherapy practice were inter-viewed to explore their understanding of the process of change (see Table1 for list of participants). They were identified as experts by having met atleast one of the following criteria: having held prestigious positions indivisions or associations related to psychotherapeutic practice, written over100 articles on psychotherapy, received awards for significant contributionsto psychotherapy practice or research, or founded a psychotherapy ap-proach. In addition to meeting these criteria, five of the participants’ have


participated in the APA’s psychotherapy demonstration videos, and atleast five also offer psychotherapy training workshops to professionals toteach their approach to therapy. All participants had extensive experienceconducting psychotherapy—over 20 years each—although two were re-tired at the time of the interview and were no longer practicing therapy.Although the interviews utilized therapists’ recall of therapeutic change,therapists interviewed have reflected extensively on their practice in theirpositions as renowned theorists and practitioners.

Procedure

Recruitment

Experts in the field of psychotherapy were contacted via e-mail andtelephone to determine willingness to participate in the study. During theinitial round of recruitment, an attempt was made to maximize the diversityof the participants in relation to their psychotherapeutic orientation, gen-der, race, and geography (Patton, 1990) so that the results would capturethemes that might differ according to individuals’ experiences. Despiteconcerted efforts to invite women and ethnically diverse therapists toparticipate, the therapists who consented to participate were mainly Cau-casian men although one Caucasian woman and one African Americanmale were interviewed.

After the initial recruitment, theoretical sampling (Glaser & Strauss,1967) was utilized. In this process, the preliminary analysis, based upon theinterviews from the initial round of recruitment, was examined for areasthat were inadequately covered. Participants were then recruited who were

Table 1. Therapists’ Approaches and Categorized Orientations

Therapist name Psychotherapy approach Orientation category

Arthur Bohart Humanist/integration HumanistLaura Brown Feminist/integration ConstructivistGerald Davison Cognitive-behavioral Cognitive-behavioralMorris Eagle Psychodynamic/object relations PsychodynamicBruce Ecker Depth oriented brief therapy ConstructivistArthur Freeman Cognitive-behavioral Cognitive-behavioralLeslie Greenberg Experiential HumanistMarvin Goldfried Cognitive-behavioral/integration Cognitive-behavioralSteven Hollon Cognitive-behavioral Cognitive-behavioralAdelbert Jenkins Freudian psychodynamic PsychodynamicRobert Neimeyer Constructivist/narrative ConstructivistDonald Polkinghorne Narrative ConstructivistDavid Rennie Rogerian/experiential HumanistDonald Spence Psychodynamic Psychodynamic


known to contain expertise in that area. All participants consented toforego anonymity as they were recruited for their expert status within thepsychotherapy community. In the end, a total of 28 therapists were con-tacted about participation. Fourteen therapists declined participation,mostly due to time limitations, resulting in 14 therapist participants.

Interviewing

All interviews were conducted either by phone or in person by the firstauthor of after receiving training by the second author in qualitativeinterviewing skills. Interviews were audio recorded and lasted about 1 hourin duration. A semistructured format with an exploratory-style of interac-tion was used to interact with participants, in which open-ended andnondirectional questions were used to restrict biasing of participant opin-ions. The primary question of the overall study was, “How do you under-stand the process of change within your own practice of psychotherapy?”Specifically, for this aspect of the study, the guiding questions revolvedaround therapists’ beliefs about the influence of their values and emotionson therapy (e.g., “Do your own values influence your therapy and if so,how?”). Subquestions and related prompts were used as necessary tofacilitate exploration and discussion. The researchers’ own therapeuticapproaches and biases are most influenced by humanistic and constructivisttheories, although both identify as integrative, with the first author imple-menting cognitive–behavioral strategies and the second author bringingexperience with psychodynamic and cognitive–behavioral therapies to thisresearch. In conducting this analysis, both researchers were motivated torecognize and challenge their assumptions about change to better identifycommon factors that tied together orientations and clearer understandingsof differences.

Analysis

This study was designed and supervised by the second author, and theanalysis was coconducted by both researchers. The interviews were tran-scribed and analyzed using a grounded theory method (Glaser & Strauss,1967). Glaser and Strauss’ original formulation of grounded theory wasutilized in accordance with Rennie’s (2000) reasoning that this formulationis more coherent within a hermeneutic philosophy of research. Thismethod uses an inductive process to develop an empirically based theoret-


ical model of a phenomenon and has been at the forefront of qualitativemethods (Ponterotto, 2005).

One way of maintaining this “groundedness” is through memoing. Theresearchers maintained memos to facilitate awareness of their own biases,to ensure that the analysis was grounded in the data, and to record theirdecisions and theoretical ideas during the analysis.

After the interviews were transcribed, the investigators studied thetranscripts and divided them into “meaning units,” or segments of text thatcontained a single idea or theme (Giorgi, 1970). The meaning units wereassigned labels that remained close to the language used by the participantsthemselves. Next, the investigators compared each meaning unit to everyother meaning unit, and developed categories that grouped units togetheraccording to perceived similarities. The categories, in turn, were comparedto one another, looking for commonalities between them. Categories werethen combined with each other, forming higher-order categories. Thisprocess of constant comparison continued until a hierarchical model wasdeveloped that described the experience of participants. This analysis wascompleted by the development of a core category—a single category thatdescribed and encompassed the experience of the process of therapeuticchange for the participants. Throughout this process, the analysts metweekly to discuss the development of the hierarchy and discuss the changesto be made. A software program, Qualitative Solutions and Research(QSR-N4), was used to aid in data management.

Additionally, the final four interviews were conducted to test forsaturation—the point at which new categories do not appear to be forth-coming and new data appears to be redundant. These interviews did notresult in any new information at the subcategory layer or higher, indicatingsaturation at the 10th interview.

The study from which this current article focuses was derived from anoverall study that consisted of a total of six clusters related to therapists’experience of the process of change in counseling. This article will focus onthe two clusters that were most germane to the issue of values in psycho-therapy—therapists’ use of moral relativism and belief in science for de-termining therapeutic expertise, and the potentially positive or negativeconsequences of therapists’ values, particularly as they were manifested intherapists’ understandings and emotional experience. The four clustersexcluded from the present discussion described managing the therapeuticrelationship, changing clients’ awareness, facilitating clients’ agency, andthe relationship between biology and psychology. It is common practice inqualitative research, due to the large amount of data accumulated, forresearchers to divide their findings into separate articles or multiple chap-ters within a book (e.g., Rennie, 1994a, 1994b).


Credibility Checks

To ensure that the data was empirically grounded, three credibilitychecks were incorporated into the study process. First, at the end of eachinterview participants were asked to reflect upon both the content of theinterview as well as the interpersonal process, allowing participants toshare information that might have otherwise been omitted and providingfeedback to the interviewer. None of the participants reported difficultysharing their responses, nor did they have substantial feedback on improv-ing the interviews.

Second, following the data analysis, the investigators sought feedbackfrom participants about the constructed model. Detailed feedback first wasrequested and received from one participant from within each theoreticalorientation. This feedback was used to further refine and clarify the model,as well as to increase confidence in the findings. Next, the revised resultswere sent to the remainder of the participants, asking them to provideeither written or verbal feedback on the results. Seven of the participants(50%) provided feedback, with three participants providing written feed-back, and four verbal feedback. None of these therapists have stronglycriticized the analysis or objected to the principles developed from theanalysis, and all responses have been quite positive. For example, DavidRennie requested permission to share the principles with students andstated, “I particularly like what you have done with intentionality: bycoincidence, earlier today, in supervising a student’s practice therapy, Iobserved that it’s important to get one’s intention straight, that once thatoccurs, one simply has to express the intention in one’s own way” (personalcommunication, January 21, 2004). Marvin Goldfried, also, stated that theprinciples “fit” nicely with his personal experience of psychotherapy inte-gration (personal communication, January 2004). This positive feedbackfrom therapists of different orientations increases our confidence in thefindings.

Third, consensus was reached between the researchers. Within a qual-itative model the use of consensus is thought to increase credibility, as itindicates that more than one investigator supports the interpretation ofdata being made (Elliott, Fisher & Rennie, 1999; Hill, Thompson, &Williams, 1997). The interpretations of both researchers were consideredequally as the first author had more experience with the interviews andprimary analysis, while the other supervised the process of interviewing,acted as a coanalyst, and had more live experience as a psychotherapist.


RESULTS

The interview transcripts were divided into1500 meaning units. Thefinal hierarchy included 3090 units because the units were assigned tomultiple categories when their meaning related to several categories. Thefollowing terminology will be used in the description of the results. Thecore category was the highest layer and subsumed six clusters. The clusterscontained 15 categories, which in turn consisted of 42 subcategories. Asdescribed previously, the present article describes the two clusters mostrelevant to the issue of values. The first cluster demonstrates how therapistsuse the values of moral relativism and belief in science to negotiatetherapeutic expertise, while the second cluster focuses on the use oftherapists’ values expressed as understandings and emotional reactions toclients. The present section is organized so that each cluster is discussed inturn, providing descriptions based on the categories and the subcategoriesit subsumed (see Table 2 for an overview of these clusters).

Cluster One: Who is the Expert? Using Moral Relativity as a GuideWhen Negotiating Clients’ Values and Belief in Science as a Guide

When Applying Theory

The first cluster focused upon the ways therapists understood therelationship between their own personal and professional values and thoseof their clients. It included two categories that will be presented in turn.

Table 2. Titles of Clusters, Categories, and Subcategories

1: Who is the expert? Using moral relativity as a guide when negotiating clients’ valuesand belief in science as a guide when applying theory1-1: Struggling between flexible and rigid theory application: Appealing to the client orempiricism

1-1A: Therapists appeal to clients’ experience1-1B: Therapists appeal to empiricism

1-2: Deference to clients’ values and concerns dictated by therapists’ degree of moralrelativity

1-2A: Value judgments inevitable1-2B: Therapists defer to client’s values1-2C: Therapists encourage evaluation of values

2: Using therapists’ values, as expressed in their emotional reactions and understandings ofclients, to monitor progress and either expand or impede clients’ self-understanding2-1: Therapists’ failure to understand the client can reduce the safety needed to createchange

2-1A: Agreeing on therapeutic goals2-1B: Barriers can reduce understanding and safety

2-2: Therapists’ feelings potentially indicative of the degree of progress2-2A: Therapist feels in contact during change, disengaged when no change2-2B: Boundary diminished during change2-3C: Therapists’ feelings and thoughts as a guide


Struggling Between Flexible and Rigid Theory Application: Appealing tothe Client or to Empiricism

Meaning units from all the therapists’ interviews (N � 14) were utilizedin the generation of this category. Therapists described being pulled bycompeting values. On one hand, expert therapists described valuing theirtheoretical and empirical knowledge to facilitate clients’ change. On theother hand, however, therapists also believed that therapy should beuniquely tailored to each client, that clients were experts on their own lives,and that therapy should be guided by clients’ expertise. Although thera-pists appeared to address this value tension in slightly different ways, twomain patterns emerged from the analysis.

Therapists appeal to clients’ experience. The majority of therapists(N � 12; 3 � Psychodynamic, 4 � Constructivist, 3 � Humanist, 2 � Cogni-tive-Behavioral [CBT]) contributed to the first subcategory by following cli-ents’ experience in the moment rather than prioritizing the theorized applica-tion of an intervention. In order to better attend to clients’ experience,therapists tried not to allow psychological theories to limit their understandingof the client. Robert Neimeyer (Constructivist) noted:

I suspect that there is a basic problem with the way in which we conceptualizeproblems as having either biological origins, or social origins, or personal origins, orsort of legal or cultural or family origins. I think that all of these domains. . .aresimply explanatory systems which have partial, but not complete relevance, to thismuch more holistic process that is called being human. So at different times I thinkit is helpful to look at human difficulties from each of these vantage points, but Idon’t think that problems themselves have an allegiance to one of those explana-tory systems.

These expert therapists expressed hesitancy about understanding theclient from a singular perspective and worried that this tendency may limithow they are able to help clients.

Half of the therapists (N � 7; 2 � Psychodynamic, 2 � Humanist, 3 �Constructivist, 1 � CBT) prioritized clients’ experience by adapting theirtherapy to the idiosyncrasies of the individual client. Believing that eachclient was unique, therapists looked to clients for important direction onhow to proceed. For example, according to Bruce Ecker (Constructivist),“It’s important for the therapist to learn from the client, calibrate to theclient, and go at the rate the client can actually go. . .the therapist literallylearns from the client how everything is working. . ..”

Because of clients’ individuality, therapists’ believed they could notunderstand, out of a specific context, how to best work through theirclients’ problems. As a result, therapists had to look to clients to under-stand their problems and adjust their interventions to clients’ needs.

Most therapists (N � 10; 4 � Constructivist, 3 � Humanist, 2 �


Psychodynamic, 1 � CBT) also thought it was important for clients to feelin control of therapy and learn to dictate its course. These therapists triedto discourage the view of clients as passive recipients of a treatment:“[Therapy] isn’t like the dentist where you go in and lay back and you getput to sleep and they do all the work and when you come out. . .everythingis fixed” (Donald Polkinghorne: Constructivist). Clients who expected tobe cured by the therapist were seen as unable to take control of thedirection of therapy and might struggle to solve problems independentlywhen therapy was terminated. As a result, therapists tried to empowerclients in therapy. Adelbert Jenkins (Psychodynamic) described how heattempted to communicate this attitude that the client is the leader at theoutset of the first session:

What’s the first thing a therapists says? From my point of view it’s, “Why don’t youbegin where you would like?” So I start off [with] the idea that you’re taking over.You’re responsible for the direction of the hour. . .I turn that over to you and I’llfollow your lead.

Placing clients in the driver’s seat was a way of privileging theirexperience and teaching them to direct the course of therapy.

Therapists appeal to empiricism. There were exceptions to this pat-tern when therapists did not wish to follow clients or appeal to them as theexpert in therapy. Some therapists (N � 5; 4 � CBT, 1 � Constructivist),mainly from a CBT orientation, described appealing to empiricism as aguide to help clients make change, usually in addition to their appeal to theclient. Therapists described relying upon empiricism to help them generatecertain types of change. As Gerald Davison (CBT) said,

[I] apply the best science that I know to moving from point A to point B–I thinkthat’s my responsibility—to use the best available means—that may be scientificallybased, that may be more clinical knowledge since the science has a long ways to go,but. . .being aware of its status as validated or not, partially supported empiricallyor not. . ..

For therapists endorsing this approach, immediate change was priori-tized over deeper understanding in session. Describing his approach,Steven Hollon (CBT) stated,

[For] people that really want to understand the roots of how things got there in thefirst place, this type of therapy isn’t always as congenial for them. The approach Ilike to take works better for people who are interested in changing, getting changeaccomplished, more so than understanding in great depth. I’m not sure I have anygreat depth to provide.

An examination of clients’ personal histories and in-the-moment ex-perience was not coherent with the ways these therapists made change.Instead, therapists appealed to empirically established interventions de-signed to efficiently reduce symptoms and teach clients needed skills.


Thus, therapists had conflicting opinions about what to value themost—their own knowledge the client’s. This tension seemed to be re-solved in two diverging ways. While the majority of therapists resolved thistension by appealing to clients as experts and relying on them to guide thetherapist, some therapists relied on empiricism to guide therapeutic deci-sions.

Deference to Clients’ Values and Concerns Dictated by Therapists’ Degreeof Moral Relativity

Within this second category there was some consensus from therapiststhat their values influenced therapy. However, there was disagreement onthe degree to which therapists should recruit clients to incorporate thera-pists’ values. Again, therapists alluded to a point of tension: Should theyattempt to situate themselves within clients’ values, or should they per-suade clients to adopt their own, potentially healthier, values?

Value judgments as inevitable. Many therapists (N � 9; 3 � Human-ist, 3 � CBT, 2 � Constructivist, 1 � Psychodynamic) described valueswithin psychotherapy as inescapable and influencing the course of therapy.For example, Gerald Davison (CBT) stated:

I think a lot of it [understanding the role of values in therapy] has got to do with thevalues of the therapist rather than thinking in terms of some sort of objectivedisease or illness that is easily agreed upon. . .like cancer or a fever that reflects aviral infection or something. [I: Do you have any way of managing your values toknow how they influence your clients?] Well, I try to be aware of it all the time. Ithink it’s important for therapists to be aware of their values, but more importantlyto be aware that psychotherapy is a value-laden enterprise, and I think that mosttherapists are not aware of this. . . and the worshipping of the DSM, even bypsychologists, has led to people overlooking or downplaying or losing sight of thevalue judgments that enter into the decisions that people are better off if they’reone way or the other.

Value judgments were seen as an inevitable, yet therapists sought toresist a priori judgments as much as possible.

Therapists defer to client’s values. The majority of therapists (N � 9;3 � Constructivist, 3 � CBT, 1 � Psychodynamic, 2 � Humanist) held amorally relativistic stance in which they tried to situate themselves withinclients’ values and used those values to guide the therapy. For example,one way of privileging clients’ values was for therapists to limit their ownpreconceptions about how change should unfold. Arthur Bohart (Human-ist) described this process:

I try not to have any goals. . .and work more with the client’s goals. So I guess thegoal is to work with the client’s goals. . ..for me, when I’m facing a client, the goal


of it is to provide some help to them and to help them solve whatever problems theywant to solve.

These therapists sought to situate themselves within their clients’ valuepositions, aligning with clients’ values above their own personal prefer-ences within sessions.

Typically, therapists were reluctant to attempt to persuade clients tochange values as they desired to respect clients and allow them to deter-mine their own values. For example,

I don’t take a position that puts me in that situation [to tell the client what to do].I’m not an expert who knows what should change. . ..so I don’t take a position thatyou should change this, or this is what needs to change. . ..And this comes from myrole as facilitator. I’m facilitating what you [the client] want to change (LeslieGreenberg: Humanist).

Therapists avoided encouraging clients’ to make decisions in any spe-cific direction, hoping to minimize the pressure on clients’ to adopt externalvalues and to stimulate the development of their own value system.

Therapists described a reluctance to force values onto clients as a corefeature of therapists, “[Being nonjudgmental] differentiates him [the ther-apist] from his [the client’s] Aunt Mame, or his grandmother or someonewho knows what he ought to do, and has a value system which they wantto impose” (Adelbert Jenkins: Psychodynamic). Because of therapists’desire to respect client autonomy, clients were offered a relative freedomto explore their own desires. There always were limitations, however, towhat values and behaviors therapists would accept.

Therapists encourage evaluation of values. The exception to deferringto clients’ values appeared when therapists (N � 11; 4 � CBT, 3 �Humanist, 2 � Psychodynamic, 2 � Constructivist) believed clients’ valueswould obstruct their progress or strongly contradicted therapists’ ownvalues about therapeutic change. At these points therapists encouragedclients to evaluate their values and consider adopting different, healthiervalues. For example, Laura Brown (Constructivist) stated, “I go with theirgoals, unless their goals are better ways to get dead. I don’t supportantisocial or self-destructive goals.” These therapists noted that they wouldnot work within client values that violated professional ethical codes suchas harming of self or others.

Two therapists reported deliberately persuading clients to embracetheir own value positions about social responsibility. Donald Polkinghorne(Constructivist) articulated this stance:

I think people have responsibility for their children, responsibility not to hurt otherpeople and in working out things to be done that would enter into my looking andworking through the options with the person. . ..if their [the client’s] point isbasically, “I don’t care, that’s not my job, my job is to take care of me,” I terriblywouldn’t be supportive of that. [I: What would you do if someone said that?] I


would say I really have different values. I think it’s very important what happenswhen you have responsibility. I’d try to remind them of that, with the hope thatthat’s just something they had forgotten or had heard somewhere, that they shouldjust look out for number one.

For Polkinghorne, the value of social responsibility was importantenough that he openly discussed his value stance with clients, and evensought to persuade them to adopt his perspective. Therapist disclosure oftheir own values was a way of confronting clients about values and engag-ing the client in value exploration that was used by several therapists.

Another way in which most CBT therapists (N � 3) reported directingclients’ values was when they confronted clients about behavior, goals, orvalues they thought were problematic. This value-challenging processseemed to be viewed by therapists as based in professional values aboutmental health. Arthur Freeman (CBT) compared this therapeutic role tothat of a friend: “Sometimes you talk to a friend and your friend turns toyou and says, ‘You know, get over it.’ And that works too. . ..if you dosomething, they’ll say, ‘You know what—that’s bullshit.’ They’ll call it whatit is.” By directly disapproving of their behaviors, therapists actively at-tempted to change clients’ behaviors and values to healthier ones.

In addition to confronting clients’ actions, some therapists (N � 4; 2 �CBT, 1 � Humanist, 1 � Constructivist) also challenged clients’ beliefs.Beliefs that seemed to be harmful to clients’ ability to change were seen asneeding to be changed. For example,

I’ve got a guy I’ve been working with. . .who belongs to a very devout fundamen-talist church, and they have a number of beliefs—the role of the husband andrelationships, the kind of things you should do and shouldn’t do—with a strongmoral, very judgmental quality to that. I think some of his distress comes from theabsolutist way that he looks at things. I don’t think it’s a necessary component ofhis particular religion. I don’t want to act in a way that’s disrespectful to thereligion, but some of the absolute statements that screw things up for him I thinkare creating some of the distress. (Steven Hollon: CBT)

Because, for this therapist, absolutist beliefs distorted people’s view ofreality, he was willing to openly challenge the client despite his desire torespect the clients’ religion. This decision-making process about when tochallenge clients’ constructions of the world is rarely discussed overtly inthe psychotherapy literature.

Although there were two ways of navigating the challenge of how tomanage clients’ values when they differed from those of the therapist, theseapproaches were not mutually exclusive. The more typical solution was toattempt to work within clients’ values by allowing them to direct therapyand make their own decisions. The second solution to this dilemma was totry to openly challenge and persuade clients to consider adjusting obstruc-tive behavior, values, and beliefs to ones therapists considered to be


healthier, and although the definition of obstruction could be very narrowfor some therapists, it was much broader for others.

Cluster Two: Using Therapists’ Values, as Expressed in Their EmotionalReactions and Understandings of Clients, to Monitor Progress and

Either Expand or Impede Clients’ Self-Understanding

While the first cluster revealed the importance of moral relativism anda belief in science when negotiating values broadly, this cluster describedhow therapists managed their own values within the therapist-client dia-logue. Therapists acknowledged that they often experienced a variety ofinternal processes during sessions which could indicate either value conflictor consensus, and the use or disclosure of these experiences had to benegotiated carefully. Therapists described two contexts in which their ownemotions and understandings might have an influence on the client: one inwhich their assumptions or experiences could misdirect the course oftherapy, and another in which therapists’ own emotional processing inreaction to clients’ values or choices could facilitate client change (seeTable 2).

Therapist’s Failure to Understand the Client Can Reduce the SafetyNeeded to Create Change

In this first category, therapists reported that they often experienced arange of emotions and understandings that could be used to gauge thera-peutic progress and the state of the relationship. Their thoughts andfeelings were not a trustworthy guide, however, when they failed to un-derstand their clients, creating an unsafe environment (N � 10; 2 � CBT,3 � Constructivist, 3 � Humanist, 2 � Psychodynamic).

Agreeing on therapeutic goals. One domain where many therapists(N � 9; 3 � Humanist, 3 � Constructivist, 2 � CBT, 2 � Psychodynamic)reported potential for value conflicts, and where agreement was vital forsuccessful therapy, was the establishment of therapeutic goals. For exam-ple, David Rennie (Humanist) explained, “I think it’s crucial that the twoof them [client and therapist] have clear senses of what they’re [doing] witheach other. There should be a plan for the therapy and strategies that gowith it.” Value disagreements about the aims of therapy could leave clientsfeeling distrustful of the therapeutic process and stifle progress.

Some therapists (N � 6; 2 � Humanist, 1 � CBT, 2 � Humanist, 1 �Psychodynamic) discussed the importance, when disagreements did arise,


of discussing them openly with clients. For example, Steven Hollon (CBT)previously described his difficulty in working with certain fundamentalistChristians because of their rigid belief systems. With this awareness, hedescribed initiating discussion with such clients about his concerns withthese belief systems and could decide if they were comfortable or not withproceeding.

When therapists and clients did not agree on the course of therapy, twotherapists (1 � Humanist, 1 � Constructivist) suggested that therapists’should understand this disjuncture as their own problem. Robert Neimeyer(Constructivist) described this occurrence:

. . .if we have such a disagreement, then that is a signal of the insufficiency of myunderstanding of where they are. Because if by definition they can’t go there, thanI need to understand how it is that they can’t go there, or why what makes it veryimportant for them not to go there, and do what for me seems like quite areasonable thing for them. I take that as to be almost inevitably a signal of theinsufficiency of my understanding.”

These therapists proposed that instead of trying to change clients, theyshould seek to better understand why the client has a different therapeuticaim and this understanding would help them to preserve the relationalsafety.

Therapist difficulties can reduce understanding and safety. A few ther-apists (N � 3; 2 � Constructivist, 1 � Psychodynamic) also alluded to thepotential for their own difficulties with clients’ choices or experiences toinfluence their bond with clients and interrupt their processing. Changeswithin the therapist’s self presentation, value discrepancies, and languageor cultural barriers were described as potential blocks in the relationship.For example, Robert Neimeyer (Constructivist) described how therapist-client differences could cause a gap in understanding between client andtherapist that could be too large to bridge:

The key issue is less the client’s ability to join me in a certain way of talking, but myability to join the client. And so sometimes when the gulf is large and I’m not ableto take up and indwell that person’s position, then the therapy bogs down. . ..some-times it will happen as a function of cultural difference.

Cultural differences were described as posing challenges as they mayreduce clients’ sense of being understood, and thus decrease the likelihoodof risking vulnerability in session.

Therapists’ Feelings Are Potentially Indicative of the Degree of Progress

Several therapists (N � 9; 2 � Psychodynamic, 2 � CBT, 3 � Human-ist, 2 � Constructivist) believed that their own emotional processing during


therapy could be used as a measuring stick of clients’ progress or process-ing. For example, “The way I’m feeling when I’m working with a patientprobably relates to how they’re doing and how I think about how they’redoing” (Gerald Davison: CBT). These therapists attended to their ownemotional processing as a way to monitor whether client change was inkeeping with their values about mental health. This process helped thera-pists assess clients’ progression and productively guide their processing.

Therapist feels contact during change, disengaged when no change.Some therapists (N � 6; 2 � CBT, 2 � Humanist, 1 � Psychodynamic, 1 �Constructivist) used their own emotional responses—such as feeling emo-tionally connected during moments of progress or change, and disengagedwhen change was not occurring—to gauge therapeutic progress as well.

I feel whether I’m being received or whether I’m being pushed away. I’m moni-toring. I’m feeling all the time whether a person is letting me closer to them, orwhether they’re distancing me from them. . .. I feel more vital and alive whenthey’re letting me closer. I get more bored—I don’t really get bored, but I get lessinterested or less alive when I feel there’s more distance. I feel very touched whenpeople get to important things. . .. they are changing by becoming authentic andreally being able to reveal their true inner experience to me. (Leslie Greenberg:Humanist)

Therapists’ emotions about the relationship were another source ofinformation that they used in session to monitor whether change wasoccurring.

Additionally, a few therapists (N � 3; 1 � Humanist, 1 � Psychody-namic, 1 � Constructivist) discussed the potential for their own emotionalreactions to be an indication of the state of the therapeutic relationship andhow well they are attending. Robert Neimeyer (Constructivist) describedusing his feelings as a gauge of clients’ experiences:

I found myself moved to tears on a number of occasions, and I take it as a given thatif my client is, him or herself, moved by some experience or anguished by someexperience, then maybe again experiencing joy as a kind of profound appreciationand joy as in this session, or anguish as in other sessions—if I don’t at least havemoisture in my eyes, then something is wrong. . .I was feeling with him and I thinkin the pure root sense of empathy—feeling in connection with another.

Therapists’ emotional reactions to events in therapy were read as apotential indicator of their understanding in the moment. This attendinghelped them to circumvent the challenges caused by disconnection de-scribed in the previous category and value differences in the previouscluster.

Boundary diminished during change. A few therapists (N � 3; 2 �Constructivist, 1 � Humanist) also described feeling that the boundarybetween self and client almost disappeared during moments of change.David Rennie (Humanist) described a moment of deep connection, “You


could feel it. It’s like feeling electricity. It’s a real connection.” In momentsof client change these therapists felt emotional closeness to their clients,and could use that to direct the client toward change.

However, the degree to which therapists emotionally reacted to clients’progress varied, and not all therapists used those experiences to the samedegree. For example, when Steven Hollon (CBT) was asked if he experi-enced any internal changes that let him know that progress was occurring,he replied, “Within who? Me?. . . No, no, no.” Articulating his didacticapproach, Hollon described the interpersonal experience of change as lessintimate.

Additionally, Morris Eagle (Psychodynamic) described the potentialfor therapists’ feelings to be misattributed to the therapist-client interac-tion:

If I feel irritated or hostile, it may well be that I’m reacting—picking up subtle cuesthat you’re emitting—but it’s entirely possible that it has more to do with me thanwhat the patient is emitting. So in that sense, it could be used to blame the patientfor my own—maybe I had an argument with my wife that morning, maybe I’mtired, and so on. So it’s a difference between viewing it as possible - that thesefeelings are a clue of what’s going on with the patient, versus stating it as a dogma.

Therapists’ emotions might best be used as a guide while maintainingsome doubt about the interpretation of their underlying emotions andengaging in a process of self-analysis.

Thus, in the moment-to-moment practice of therapy in relation tovalues, therapists’ internal experiences could be used for both the benefitand detriment of clients. These expert therapists tended to believe thatattunement to these emotions could help to reduce value conflicts orincrease their possibility, depending on the degree of understanding andconnection that exists between client and therapist. These therapists de-scribed walking a fine line in which they attended to their feelings and usedthem as a gauge of their implicit values about mental health progress, butalso were cautious about the possibility that misunderstandings, misattri-butions and overconfidence could impair their assessments.

Core Category

The analysis of all six clusters led to the development of a corecategory—a single category that described the moment-to-moment processof guiding psychotherapy. Although the core category resulted from iden-tifying a common theme across the six total clusters, four of which couldnot be described in this article (see Williams, 2004, for a complete descrip-tion of the project findings), the intersections between the clusters pre-sented and the core category therefore will be emphasized in the following


section. This category contained five components that function acrosstherapy orientations and across the clusters, with therapists focusing on, inany given moment, the component that is needed to continue the processof change: Therapists sought to (1) stimulate clients’ curiosity about theirown experience to assist them to (2) sustain the exploration of distressingexperiential states in order to (3) generate experiences of difference. Theseexperiences, in turn, could lead to (4) a process of reflexive symbolization,during which therapists provide the structure to (5) integrate these differ-ences. This core category suggests that the central function of therapists,across psychotherapy orientation, is to assess which component is relevantat a given moment and guide clients to accomplish this task, at times inconjunctions with other components.

One of the main accomplishments of this core category was the way itreconciled the different therapeutic orientations of the therapists inter-viewed. For instance, while humanistic orientations emphasized experi-ences of difference generated through emotional reflection and psychody-namic orientations emphasized differences in relational experiences,cognitive therapists emphasized the creation of difference through thestructuring of tasks. As this finding sheds light on the common processesbeneath the different orientations, it also helps to explain the differencesmanifested within interventions. The following section will develop anunderstanding of why differences in value management might arise, despitethis common psychotherapeutic activity, due to the mechanisms utilized tocreate experiences of difference.

DISCUSSION

This study has shed light upon processes that expert therapists usewhen negotiating value conflict, explicating strategies that were not previ-ously available and also suggesting new approaches for the development ofprinciples to guide practice. Instead of retaining the theoretical approach tothe problem of values that is typical in this literature, the study of lived-experience has allowed for solutions that are innovative and more sensitiveto the context of practice. We have chosen to study this experience at thelevel of therapists’ intentionality, rather than having behavioral cues be-come the site of investigation to facilitate the application of our findings.Expert therapists adjusted and transformed their treatments based on theirconceptualization of the process that the client was engaged in within thecontext of the therapeutic relationship. Through studying intentionality, welearn about the dynamics to which therapists are attending, their hesitan-cies in pushing forward, and the rationale that guides the selection and


form of an intervention. At the same time, this study sheds light onbehavior to the extent that these therapists can be expected to be aware ofhow their philosophies and intentions merge with their practice—giventheir positions as experts this assumption may be warranted. Althoughfurther research using a different design would be necessary to clarify howclosely intentions and behavior are related, the development of intentionalguidelines that have empirical support may facilitate such exploration. Thisstudy has unearthed the value negotiation that underlies the specific inter-ventions and common processes that span psychotherapy orientations asclients are guided through moment-to-moment processes of change. Fur-ther research also can assess the efficacy of the preliminary principlespresented below.

Three credibility checks were incorporated into the study, allowing forconfidence in the analysis. In addition to developing consensus between thetwo researchers, feedback was given on the data collection process by allparticipants following each interview. In addition, feedback was given byhalf of the participants on the results, including at least one therapist fromeach psychotherapy orientation grouping. Therapist feedback was quitepositive, with one therapist already indicating his use of principles toimprove his supervision of psychotherapy trainees.

Principles of Treatment

An examination of this analysis resulted in the development of fiveempirically derived principles that describe how expert therapists navigatetheir decisions about how to manage values within therapy. These princi-ples were derived by conducting a hermeneutic analysis of the groundedtheory findings—that is, points of tension (within and between therapists)were identified in the grounded theory analysis, and the assumptions andbeliefs described were examined to see if it was possible to explicate aclearer understanding of why at certain points some therapists might adoptone path while others endorsed a different route. As investigators, weexperienced a richer understanding of counseling through these principles.We found that they transformed both our practice and ability to transmitclinical wisdom. When these principles were circulated back to the thera-pists, we received positive feedback from therapists across each orientationabout these principles’ resonance with their practice, making this the firstset of integration principles of our knowledge to receive strong endorse-ments across orientations.


Cluster 1: Who is the Expert? Using Moral Relativity as a Guide WhenNegotiating Clients’ Values and Goals, and Belief in Science as a Guide

When Applying Theory

The point of tension that became apparent in this cluster was thetherapists’ differences in answering the following question, “Should I placegreatest value on my own knowledge and values, or should I look to myclients’ values and knowledge to guide the process of change?”

Principle 1.1: Expert therapists tended to prioritize clients’ experiencesand sought clients’ expertise to guide their therapeutic solutions unless theybelieved that clients were deficient in the skills or abilities necessary to guidethe change process, in which case they prioritized their own knowledge as thebasis of therapeutic decisions. Therapists recognized they were equippedwith specialized theoretical and empirical knowledge on the process ofchange, but at the same time, clients were recognized as possessing exper-tise on their own experiences. Thus, in resolving this tension, most of theexpert therapists first looked to the client to guide the exploration (seesubcategory 1-1A). When therapists found that clients were incapable ofdirecting that process (e.g., were blocked, lacked the skills) they relied ontheir own clinical wisdom, and turned to historically proven and empiricallytested interventions to guide the process (see subcategory1-1B). At thesetimes, the use of more structured interventions helped clients begin todirect their own processing.

Principle 1.2: Eminent therapists desired to respect clients’ values andtheir resultant goals by working within them during explorations unless theywere thought to actively impede the change process, according to therapists’values, in which case therapists would directly engage clients in evaluatingthat value or goal. Therapists wanted to respect clients’ perspectives andvalues, and avoid imposing their own values or goals on to clients. As aresult, they tried to work within clients’ value systems and use clients’values and ensuing goals to guide the therapeutic process (see subcatego-ries 1-2B and 2-3B). However, some value differences were so stark and sodangerous to the goal of therapy (e.g., desiring self-destruction, or notrespecting therapists’ boundaries), or their own personal values aboutmental health (e.g., neglecting social responsibilities) that therapiststhought it was important to help clients more consciously evaluate thevalues or goals at hand and reconsider their appropriateness (see subcat-egories 1-2C and 2-3B). To avoid creating an environment where clients’values were minimized, where clients felt unsafe to disclose how they trulyfeel for fear of judgment, or where therapist value imposition was un-checked, therapists’ value disclosure was accompanied by directness andhumility, in that clients were free to select values without the therapist’s


condemnation, although the ensuing discussion might uncover incompati-bilities leading to a mutual decision to discontinue therapy.

Cluster Two: Using Therapists’ Values, as Expressed in Their EmotionalReactions and Understandings of Clients, to Monitor Progress and Either

Expand or Impede Clients’ Self-Understanding

Therapists acknowledged that they often experienced emotional reac-tions and understandings while with clients that could be used to guide orhinder their practice, leading to the question, “Should I use my ownexperience to facilitate change?”

Principle 2.1: Therapists used their own emotionally informed reactionsto track the state of the therapeutic relationship and gauge whether therapywas progressing according to therapists’ mental health values, unless theirchange process did not rely on the relationship, in which case they did notutilize this experience. Those therapists who relied more heavily on thetherapeutic relationship as a vehicle of change tended to describe relyingon their own experiential processing to track clients’ progress, the state ofthe therapeutic relationship, and the degree to which clients progress wascongruent with their own values. These tended to be humanistic, construc-tivist, or psychodynamic therapists who created experiences of differenceby guiding clients to attend to vulnerable emotion within session or bygenerating a new experience of relationship with clients. Those therapistswho led clients to experiences of change through the generation of tasks orintellectual exploration tended not to describe relying on their own emo-tional processing to the same degree as it was not as relevant to, or couldinterfere with, the clear structuring of interventions in intellectual orbehavioral engagement. These therapists tended to identify with cognitiveor constructivist orientations. As educational or out-of-session tasks re-quired less client disclosure, subtle value differences might not be asimportant as in therapies that created change through in-session explora-tions of clients’ vulnerability. As thorough exploration of clients’ valuesmight not be as central in these approaches, therapists’ attention to theirown emotions might not be as necessary as cues for slight client-therapistdiscrepancies as they might not hold as much influence on the therapeutictask.

Principle 2.2: Therapists sought to develop a mutual understanding withclients during the process of therapy unless differences became too great fortherapists to understand, in which case therapists sought outside resources ordiscussed those differences with clients. When disagreements appearedbetween therapist and client, these expert therapists sought to preserve the


safety of the therapeutic relationship—typically by trying to better under-stand clients’ perspectives and asking questions to clarify their understand-ing of the clients’ context. However, some differences (e.g., culture, lan-guage, value conflicts) were too large to bridge, and therapists were unableto help clients to progress without seeking outside resources. This principleemphasizes expert therapists’ tendency to view value differences as areflection of their own deficit in information or understanding. It explicatesa decision making process that helped therapists navigate the complexity ofinteracting with clients with different worldviews.

Implications for Training and Practice

Empirically derived principles, such as those above, could be useful intraining therapists to make reasoned moment-to-moment treatment deci-sions and to consider the principles underlying their work in relation to thecontext at hand. By identifying points of tension, the concerns that ap-peared to challenge therapists are brought to light. In this way, beginningand practicing therapists are not encouraged to mechanistically mimictherapeutic interventions without context; rather, they are taught to usecontextually sensitive principles to make decisions on how to guide theprocess of therapy. These intentional and empirically derived principlesallow therapists to consider their interventions in a flexible manner thatshifts depending on relational or situational factors, invoking new strate-gies to maintain treatment coherence.

Because the method used within this study interrogated the therapists’intentional processes, it is able to describe those understandings mostuseful to their practice of psychotherapy. This approach to research mayproduce principles sensitive to the moment-to-moment process. The pro-posed principles are more nuanced than the previous suggestions fortherapists to either hold their values in abeyance or to disclose their valueswhenever possible.

In a parallel study identifying principles based upon interviews withclients, researchers have found that clients want therapists to challengetheir values in certain instances and are distressed when therapists accepttheir assumptions too easily (Levitt, Butler, & Travis, 2006). Additionally,evidence indicates that clients often are able to resist therapists’ values inmany ways (Rennie, 1994b). Unfortunately, this resistance often takescovert form, such as feigning compliance, or saying what they think thetherapist would like to hear, while inwardly thinking differently. Use of theabove principles, which were implicitly used by expert therapists, can helppractitioners decide when to enter into overt conversations with clients.


This work builds on that of feminist (e.g., Cammaert & Larsen, 1989) andmulticultural researchers (e.g., Sue & Sue, 1990), who have been propo-nents of increased self-awareness and understanding of therapist values(see Williams & Levitt, 2005, for comparison of multicultural and valuesliteratures). This study extends that research by not only encouragingimproved value awareness, but by also providing practitioners concreteprinciples for how to manage their values in a sensitive manner.

This research highlights how explorations of abstract values might notadequately relate to the types of therapy decisions that characterize theprocess of being in therapy. A client’s shift in prioritizing one value overanother might be hard to assess outside of the context of mental health forthat client. Similarly, a therapist’s intervention to challenge a value mighthold different meanings, depending on the therapist’s motive for thisintervention. Research that examines the intentions underlying therapists’interventions, particularly as they function across therapeutic orientations,may more clearly elucidate the connections across orientations and facili-tate both the negotiation of value conflicts and the process of change inpsychotherapy.

Implications for Psychotherapy Integration

This approach to developing moment-by-moment principles is notmeant to dictate to therapists sets of behaviors to be followed at givenpoints in therapy. Instead, by elucidating eminent therapists’ internal pro-cesses, these principles encourage therapists to consider the intention thatis at hand in their own process of guiding clients and to be mindful to selectinterventions that are coherent with that intention. After recognizing theirintentions, therapists may find that many different interventions can becongruent with one intention.

Enacting integration at the level of intention creates a platform forpractice that can encompass a broad range of interventions in a theoreti-cally coherent manner and escapes the problems of haphazardly combiningtechniques (Neimeyer, 1993; Slife & Reber, 2001). This focus on intention-ality keeps the integrative process from becoming trapped in the reconcil-iation of interventions and, instead, focuses the process on coherencewithin the direction of therapeutic tasks. The core category and the prin-ciples from this study (see Williams, 2004, for complete set of principles)can guide therapists to integrate approaches in a philosophically coherentfashion and serve as a metaorientation for psychotherapy integration.


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