EVIDENCE-BASED CASE STUDY

Exploring Corrective Experiences in a Successful Case ofShort-Term Dynamic Psychotherapy

Myrna L. FriedlanderUniversity at Albany/SUNY

Olga SutherlandUniversity of Guelph

Steven SandlerAlbany Medical College

Laura KortzUniversity at Albany/SUNY

Shaina BernardiUniversity at Albany/SUNY

Hsin-Hua LeeUniversity at Albany/SUNY

Agata DrozdUniversity of Guelph

The concept of corrective emotional experience, originally formulated by psychoanalysts Alexander andFrench (1946), has been redefined by contemporary researchers to be theoretically nonspecific, that is,as “coming to understand or experience an event or relationship in a different or unexpected way”(Castonguay & Hill, 2011). Using postsession questionnaires, videotapes, and posttermination inter-views, we explored whether (and how) a corrective experience occurred in a successful case of short-termdynamic psychotherapy (STDP; Davanloo, 1980). A 35-year-old woman suffering severe panic attackswas seen for 31 sessions by an experienced STDP therapist. The questionnaires and interviews focusedon (a) perceived intrapsychic and interpersonal changes, and (b) how these changes came about. Attermination, the client reported complete symptom relief, greater self-acceptance, improved relationships,and more emotional flexibility. Her corrective experience was evident in the qualitative themes, whichshowed that she came to understand and affectively experience her relationships with both parentsdifferently. Moreover, the themes reflected both STDP-specific (e.g., confrontation of defenses) andnonspecific (e.g., rapport, acceptance) mechanisms of change. Conversation analysis (Sacks, 1995) ofwhat the client described as “the ‘gentle shove’ of questions that make me see what I have been tryingto ignore since childhood” showed, on a microlinguistic level, how she overcame resistance to strongemotional experience and expression.

Keywords: corrective experience, short-term dynamic psychotherapy, conversation analysis

Supplemental materials: http://dx.doi.org/10.1037/a0023447.supp

Psychoanalysts Alexander and French (1946) coined the termcorrective emotional experience to refer to processes that result in

a client’s emotional and intellectual understanding of the differ-ence between early conflict experiences that were unresolved andpresent-day circumstances and relationships. According to Alex-ander and French, to bring about a corrective emotional experi-ence, the analyst must reexpose the client to the earlier emotion-charged situation but in a more positive interpersonal context, bypurposefully creating a transference relationship that contradictsthe client’s past traumatic experience. Contemporary analysts,however, reject the idea that therapists should deliberately contra-dict the client’s previous relational experience by actively manip-ulating the transference. Rather, empathic attunement in and ofitself creates the corrective emotional experience, with changecoming about when “clients find their own experience within thetherapeutic alliance” (Knight, 2005, p. 39).

Taking a step further, a group of senior psychotherapy research-ers reconceptualized corrective experience from a theory-neutral

This article was published Online First October 3, 2011.Myrna L. Friedlander, Department of Educational and Counseling Psychol-

ogy, University at Albany/SUNY; Olga Sutherland, Department of FamilyRelations and Applied Nutrition, University of Guelph, Guelph, Ontario,Canada; Steven Sandler, Department of Psychiatry, Albany Medical College;Laura Kortz, Department of Educational and Counseling Psychology, Univer-sity at Albany/SUNY; Shaina Bernardi, Department of Educational and Coun-seling Psychology, University at Albany/SUNY; Hsin-Hua Lee, Departmentof Educational and Counseling Psychology, University at Albany/SUNY;Agata Drozd, Department of Psychology, University of Guelph.

Correspondence concerning this article should be addressed to Myrna L.Friedlander, Department of Educational and Counseling Psychology, ED220, University at Albany/SUNY, 1400 Washington Avenue, Albany, NY12222. E-mail: mfriedlander@uamil.albany.edu

Psychotherapy © 2011 American Psychological Association2012, Vol. 49, No. 3, 349–363 0033-3204/11/$12.00 DOI: 10.1037/a0023447

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perspective (Castonguay & Hill, 2011). At the 2007 and 2009 PennState Conferences on Corrective Experiences, these researcherscollaboratively defined corrective experiences in psychotherapy as“those during which a person comes to understand or affectivelyexperience an event or relationship in a different or unexpectedway” (Castonguay & Hill, 2011). This definition, like Knight’s(2005) contemporary analytic view, does not require that changeoccur specifically through the transference relationship.

We reasoned that successfully treated clients should show evi-dence of the Penn State researchers’ transtheoretical view ofcorrective experience. We reasoned, further, that mechanisms ofchange associated with the corrective experience should reflecttheoretically nonspecific factors (e.g., a strong therapeutic rela-tionship; Lambert & Barley, 2001; Norcross, 2002) as well asfactors specific to the theoretical approach taken by the therapist.In this qualitative case study, we explored whether (and how) acorrective experience came about in the successful treatment of aclient who was seen in short-term dynamic therapy (STDP; Da-vanloo, 1980; Davanloo, 1990; Della Selva, 1996). According toDavanloo (1990), STDP should result in reduced symptoms ofemotional distress and improved interpersonal functioning; themost ambitious STDP practitioners aim for the complete resolutionof the patient’s neurotic problems within 40 sessions. Supportingthis theoretical claim, a meta-analysis of 23 randomized controlledtrials of brief dynamic psychotherapy (Abbass, Hancock, Hender-son, & Kisely, 2006) showed substantial posttreatment andfollow-up effect sizes. These results suggest that psychologicalchanges set in motion during psychodynamic therapy tend to besustained over time (Shedler, 2010).

Qualitative case studies have a long tradition within psycho-analysis, beginning with Sigmund Freud (Strachey, Freud, Stra-chey, & Tyson, 1953–1974). In 1993, Hilliard described the valueof systematic N � 1 qualitative studies to explore mechanisms ofchange in successful therapy cases. For example, in a recent studyof dynamic psychotherapy (Ulberg, Høglend, Marble, & Sørbye,2009), a “distinctively good outcome” case was purposefully se-lected to explore the sequential process of change (p. 231). Resultsshowed that after the client’s depression lifted, she achievedgreater insight and, finally, improved interpersonal functioning.

Qualitative case studies can be confirmatory or exploratory(Hilliard, 1993). Because the present study was based on a recon-ceptualized definition of corrective experience (CE), we adoptedan exploratory stance. That is, we investigated “propositions”(Miles & Huberman, 1994, p. 75) about the CE in the client’spostsession questionnaires, in posttermination interviews withboth client and therapist, and in the actual therapeutic discourse.Unlike hypothesis testing in quantitative research, qualitative prop-ositions are tested in interaction with the developing themes, whichare “grounded” in narrative data (Maxwell, 2005). In the presentstudy, we used inductively developed themes in the interview andquestionnaire data to determine (a) whether a CE did or did notoccur (i.e., whether the client and therapist would describe correc-tive changes consistent with the Penn State definition) and, if so,(b) how the CE came about (nonspecific and STDP-specificchange mechanisms).

There are several models of brief dynamic therapy. In contrastto other dynamic approaches that emphasize understandingdysfunctional relationships through analysis of the therapeuticrelationship, Davanloo’s (1980, 1990) STDP focuses more on

confrontation of defenses as they arise in the therapy (Diener &Hilsenroth, 2009). Specific mechanisms of change include facili-tating emotional experiencing, particularly in relation to troubledpast relationships, and fostering insight. When the therapist repeat-edly points out incongruencies between verbal and nonverbalbehavior, or between the content and expression of disturbingmaterial, the client learns to recognize his or her idiosyncraticdefense mechanisms and gains access to unconscious thoughts,feelings, and impulses. Exploration of affectively charged materialresults in a greater understanding of the connections betweencurrent behavior and past and present relationships.

STDP therapists use a variety of techniques, including confron-tation, empathy, and imaginal exposure, that is, encouraging cli-ents to imagine that a significant person is present and then toaddress this person directly with genuine emotion (Davanloo,1990; Della Selva, 1996). Techniques like these help clients movepast their defenses (including character defenses) and experiencedisavowed affect. Ultimately, successful clients work throughpainful attachment ruptures from childhood and reestablish theircapacity for emotional expression (Sandler, 2007). STDP-specificchange processes reflect those that Blagys and Hilsenroth (2000)described as distinguishing psychodynamic therapy fromcognitive–behavioral therapy. These seven distinctive processesinclude exploring (a) affect and emotional expression, (b) theavoidance of disturbing thoughts and feelings, (c) reoccurringthemes and patterns, (d) fantasies, (e) past experiences, and (f)interpersonal relationships, including (g) the therapy relationship.Blagys and Hilsenroth concluded that among these distinctiveprocesses, the focus on emotional expression has the most empir-ical support. In line with this conclusion, a meta-analysis ofpsychodynamic treatments (Diener, Hilsenroth, & Weinberger,2007) showed that facilitation of client affect was statistically andsubstantially related to a variety of therapy outcomes. In an inves-tigation of short-term dynamic therapy, for example, Hilsenroth,Ackerman, Blagys, Baity, and Mooney (2003) reported that thetherapist’s encouragement of emotional expression and “address-[ing] the patient’s avoidance of topics and shifts in mood” (p. 355)were significantly related to a reliable reduction in clients’ depres-sive symptoms.

In psychodynamic therapy, it is not sufficient to simply “makethe unconscious conscious;” rather, a strong therapeutic relation-ship must accompany technical interpretations (e.g., Knight,2005). Thus we expected client and therapist to discuss theirrelationship as well as other change factors that are common acrosstheoretical approaches. In the literature on transtheoretical changemechanisms, there has been a fair amount of research on whatclients see as therapeutic. Pioneering studies were published bySnyder (1961); Strupp, Fox, and Lesser (1969); Orlinsky andHoward (1975); and Elliott, James, Reimshuessel, Cislo, and Sack(1985). Elliott and James’s (1989) review of studies on clientexperiencing concluded that whether the unit of analysis was thesession, an event within a session, or the whole treatment, clients’reports of therapeutic impact reflect the experience of help or reliefwithin the therapeutic relationship as well as the accomplishmentof tasks. Across studies (with surveys, open-ended questionnaires,videotape-assisted recall, and observer ratings), the most commontask-related impacts were self-understanding or insight, guidance,self-awareness, and taking responsibility; the most common rela-tional impacts were expression or catharsis, reassurance/

350 FRIEDLANDER ET AL.

confidence, relief, and feeling understood (Elliott & James, 1989).In a 2007 meta-analytic synthesis of qualitative research on client-identified impacts, Timulak added several categories to thosepreviously identified by Elliott and James: client involvement,behavioral change, empowerment, and personal contact. Empow-erment refers to recognition of personal development or strengthand interpersonal validation. Personal contact refers to experienc-ing the therapist “not like a doctor but rather like a fellow humanbeing” (p. 310).

An important element in the present study was a conversationanalysis (CA) of therapy excerpts, which we undertook to eluci-date specifically how changes in the client took place. Consistentwith Freud’s view that psychotherapy is a “talking cure,” CAprovides a method for understanding how change evolves betweenpeople in therapeutic discourse (Forrester & Reason, 2006; Pera-kyla, Antaki, Vehvilainen, & Luedar, 2008). Simply put, conver-sation analysis reveals, on a micro level, how speakers draw uponand extend one another’s meaning and intentions, thereby negoti-ating their shared experience (Weingarten, 1991).

Several CA studies have been conducted of family therapy(Gale, 1991; Sutherland & Strong, 2010) as well as psychoanalyticpsychotherapy (e.g., Forrester & Reason, 2006; Madill &Barkham, 1997; Madill, Widdicombe, & Barkham, 2001; Pera-kyla, 2004; Vehvilainen, 2003; Viklund, Holmqvist, & Nelson,2010). Madill and Barkham used discourse analysis to examineone session of psychodynamic therapy, focusing on the sociocul-tural resources, such as cultural meanings, category systems,metaphors, and so forth, informing the participants’ situatedmeaning-making. Whereas Madill and Barkham studied culturaldiscourses of autonomy/individualism and dependence/related-ness, in the present study the emphasis was on the communicativepractices and devices that afforded the participants to developinteractions that the client experienced as therapeutic (Heritage,1984). To our knowledge, this is the first CA of how correctivechange comes about in short-term psychodynamic psychotherapy.

Method

Participants

The larger, multisite qualitative study from which the presentcase was drawn was conducted by five researchers who partici-pated in the Penn State Conferences on Corrective Experiences(Heatherington, Constantino, Friedlander, Angus, & Messer,2011). In this study, clients provided written descriptions of thenature of any important changes since beginning therapy (“whatchanged”) and the perceived mechanisms of change (“how itchanged”) after every fourth psychotherapy session. Data weregathered from clients who presented for treatment at five sites:three university training clinics for clinical psychology doctoralstudents, a community mental health center, and a hospital outpa-tient group practice affiliated with a medical college.

The present treatment took place in the hospital practice and wascovered by a third-party payor, with a nominal copayment by theclient. This case was selected for intensive analysis because in herpostsession interview, the client described her experience in ther-apy as highly successful, and the therapist, who was trained andexperienced in STDP, considered the case to be representative ofhis practice.

Client.1 A 35-year-old, White woman, “Ms. K,” lived withher partner, a dairy farmer, in the same rural community in whichshe was raised. A nurse’s aide, Ms. K presented for treatment withsevere panic attacks and inappropriate outbursts of anger at workand at home. Although she had previously been seen by a nursepractitioner for medication and by a social worker in a countyclinic for three therapy sessions, Ms. K found these providers to be“patronizing.”

On presentation at intake, Ms. K said she was “having a break-down” and described panic attacks and ongoing, intense anxiety,symptoms that were triggered by feeling unappreciated at work.During the course of therapy, Ms. K revealed that she also feltunappreciated and neglected by her mother. A pivotal memoryrevealed that when Ms. K was five years old, her mother literallyforgot her while shopping in a store and drove home without her.

Ms. K’s initial symptoms abated considerably with the help ofmedications that had previously been prescribed for her by thenurse practitioner: 100 mg of Seroquel and 0.25 mg of Xanax.Although still angry and irritable when she began seeing thepresent therapist, Ms. K took these medications sparingly andreluctantly, discontinuing their use altogether after a few weeks intherapy. Psychotherapy ended by mutual agreement after 31 ses-sions. At the time of the posttermination interview several weekslater, Ms. K was symptom free and reported increased self-acceptance and improved interpersonal relationships.

Therapist. “Dr. G” was a 61-year-old, white psychiatrist,who had 18 years of full-time clinical experience at the time Ms.K was seen. He had received three years of didactic training andsupervision in STDP and regularly worked in that modality (withsuitable clients) for more than 17 years. A faculty member in themedical college, Dr. G teaches an annual seminar on STDP topsychology interns and psychiatry residents.

Instruments

Postsession questionnaire. In the larger study, clients com-pleted a two-item, open-ended questionnaire immediatelyfollowing every fourth session. The first question was designed todetermine if the client perceived a CE (as defined by the PennState researchers) and, if so, the nature of that experience:

“Have there been any times since you started the present therapythat you have become aware of an important or meaningful change(or changes) in your thinking, feeling, behavior or relationships?This change may have occurred in the past four weeks or any timeduring the present therapy. Please describe such change (orchanges) as fully and vividly as possible.”

Note that this question was deliberately worded to elicit a broaddescription of change and to allow clients to indicate no or mini-mal change. So as not to prompt social desirability bias, the termcorrective was deliberately omitted (Heatherington et al., 2011).The second question was designed to elicit the client’s perceptionof the mechanism of change: “If yes, what do you believe tookplace during or between your therapy sessions that led to suchchange (or changes)?”

Posttermination interviews. Ms. K and Dr. G were inter-viewed independently by different individuals after therapy ended.

1 Some aspects of the client’s identity were altered to protect her ano-nymity.

351CORRECTIVE EXPERIENCES IN STDP

As shown in Appendix A, parallel versions of the interview pro-tocol were used. The semistructured questions, which gave theinterviewers wide latitude in following up, were organized in threesections. The opening questions provided background material thatwas considered necessary to elicit rich descriptions of the therapyand perceived change mechanisms. The second and third sets ofquestions referred to broad corrective experiences and to specificwithin-therapy corrective experiences, that is, CEs attributed totreatment or to the therapeutic relationship.

Procedure

All clients in the multisite investigation were asked to vol-unteer for a study on “clients’ perceptions of psychotherapy.”Clients were told that participation was voluntary and confi-dential and that they could withdraw at any point withoutcompromising their treatment. Furthermore, all clients wereassured that no identifying information would be included inany publications resulting from the study. Clients in the hospitalpractice signed a separate consent allowing videotapes of theirsessions to be used for training and research. No incentive wasoffered for participation.

Because Ms. K’s therapy was ongoing when data collection forthe larger study began, the first postsession questionnaire wasadministered to her after Session 16 and every fourth sessionthereafter (i.e., Sessions 16, 20, 24, and 28). Thus one limitation isthat her descriptions of CEs only pertain to changes that sheperceived in the latter half of her treatment. On the other hand, wereasoned that if a CE did occur, it would most likely be evident inthe latter half of treatment.

After termination, two of the authors conducted separate inter-views with Ms. K and Dr. G. Transcripts were made of theaudio-taped interviews by another author. For the conversationanalysis, two different authors watched the three available video-tapes of Sessions 16, 24, and 28, which immediately preceded theadministration of the questionnaires. Research questions in CAmay be generated either prior to or during the analysis. In line withthe exploratory nature of the study, the researchers practicedunmotivated looking (ten Have, 1999) or openness to identifyinginteresting phenomena that might be reflective of psychodynamicconcepts. The assumption behind this approach is that analysis isalways “motivated” by something; otherwise, researchers wouldnot be looking for anything in the first place (ten Have, 1999).Although we were attuned to STDP-specific change mechanisms,our initial examination of the transcripts was more discoveryoriented (Mahrer, 1992). This is how we became interested in thediscursive accomplishment of resistance talk. In reading throughthe transcripts, we noted multiple examples of how specific aspectsof the client’s conduct were mutually attended to and referenced as“resistance”—something to notice and overcome. We discernedand examined this phenomenon in depth due to its prominence inthe participants’ discourse. We selected, transcribed, and analyzed17 segments containing implicit or explicit references toresistance.

Qualitative Analyses: Posttermination Interviews andPostsession Questionnaires

We used thematic analysis (Braun & Clarke, 2006) to identifyand describe patterns (themes) and differences within and across

the participants’ responses to interview questions. The first stepof the qualitative analysis involved identifying narrative themesfrom the two posttermination interviews and the postsession ques-tionnaire data. The second step involved examining these themesalongside the “propositions” (Miles & Huberman, 1994, p. 75)related to (a) the Penn State definition of corrective experience and(b) STDP-specific and theoretically nonspecific mechanisms ofchange. The presence of a corrective experience would be inferredif specific interview and/or questionnaire data indicated that duringthis therapy experience the client had had a new and significantaffective experience or cognitive understanding of either an eventor a relationship.

Four of the authors (one female PhD-level counseling psychol-ogist and three female doctoral students in counseling psychology)began by familiarizing themselves with the data by repeatedlyreading the participants’ responses. Next, they generated initialcodes by systematically coding the data and gradually developingthemes. Braun and Clark (2006) distinguish between data-drivenand theory-driven theme development. In a data-driven analysis,themes are closely tied to the researcher’s observations of the data.Theory-driven analysis, on the other hand, indicates that research-ers approach the data with specific questions and that the coding isconducted in light of this focus. Our analysis was both data-drivenand theory-driven, in that it involved the interplay of inductive anddeductive processes.

The four judges came together to discuss and compare theirthemes for each transcript. Themes were retained if they wereidentified by at least two judges. In this way, two final lists ofthemes were created, one from the client’s interview and one fromthe therapist’s interview. Finally, the client’s written responses tothe four postsession questionnaires were analyzed. Themes in theclients’ written answers were compared to the previously identi-fied themes that had emerged from the client’s postterminationinterview.

Conversation Analysis

CA originated in sociology as a way to describe the order,structure, and sequencing of language (Forrester & Reason, 2006;Sacks, 1995; Sacks, Schegloff, & Jefferson, 1974). In contrast toother forms of qualitative analysis, CA focuses not on narrativecontent but on how interaction is constituted as orderly and mu-tually intelligible, conversationally turn-by-turn. In CA, meaningis an interactive process that requires meticulous ongoing coordi-nation and comanagement of intentions, preferences, and under-standings by all conversing parties. Speakers mutually signal eachother, through various interactive practices (e.g., “uh huh,” “yeah,”head nodding), that a shared understanding has been established(or not) at the level of each speaking turn. Hence, while one partyspeaks, the other party is not inert but rather is actively influencingthe constitution of the speaker’s turn (Sacks, 1995). That is, aspeaker adjusts the form and delivery of an utterance in light ofcontinuous verbal and nonverbal feedback from the listener. CAfocuses not only on how individual speaking turns are constitutedbut also how they are linked and coordinated to create an orderlyinteraction and on the overall organization of a conversation (e.g.,projects or activities accomplished within it).

The segments selected from Sessions 16, 24, and 28 wereanalyzed by two different authors (a female PhD-level counseling

352 FRIEDLANDER ET AL.

psychologist and a female researcher with a master’s degree inpsychology) who were not involved in the data collection or thequalitative analysis described above. Using the CA steps outlinedby ten Have (1999), these judges incorporated Gale’s (1996)recommendation to explore the details of rhetorical account con-struction, that is, how different versions of events or experiencesare assembled and negotiated within and across conversationalturns. To identify and examine participants’ specific interactionalpractices (e.g., rules of turn taking) and devices (e.g., words like“okay,” “uh huh,” and “oh” that allow actions to be coordinatedwithin an interaction), the judges were guided by conventional CAconcepts: turn-taking organization, overall structural and sequen-tial organization of interaction (e.g., question-answer, accusation-defense sequences), repair organization (how speakers self-corrected or corrected each other), and turn design (e.g., words orphrases used).

According to conversation analysts, in “designing” actions andinterpreting the actions of others, speakers noticeably treat themicrodetails of talk (e.g., pauses, inhales and exhales, overlappingtalk, changes in volume or intonation) as relevant and significant(Heritage, 1984). Such details of talk are “captured” using Jeffer-son’s conventional CA transcription system (see Table 1; Atkinson& Heritage, 1984). Throughout the analysis, the judges focused onunderstanding how client and therapist produced and made senseof each other’s actions in interaction (Sacks et al., 1974). Toaccomplish this, they continuously asked themselves: What is thespeaker doing in this turn? How is he or she doing it? The latterquestion was answered by observing how the person addressed bythe speaker understood the previous turn and designed his or hersuccessive speaking turn.

Results

Analysis of the client’s postsession questionnaires showed con-sistency with the themes that emerged from the two interviewnarratives. Comparison of the themes in the client’s and therapist’sinterviews indicated that, by and large, the nature and mechanismsof change were seen similarly. The client had relatively more tosay about the therapist factors that led to change, whereas thetherapist had somewhat more to say about the treatment-specific

factors. Additionally, the client mentioned specific feelings andbehaviors that occurred in the treatment, whereas the therapistdescribed the process in more general, overarching terms.

Five major themes emerged related to important therapeuticchanges: (a) symptom relief; (b) strength, self-awareness andself-acceptance; (c) greater emotional flexibility and control; (d)resolution of unfinished business from childhood; and (e) moreadaptive interpersonal relationships. Whereas the first threethemes reflect general changes within the client, data within thelatter themes, resolution of unfinished business from childhood andmore adaptive interpersonal relationships, were examined to de-termine whether the client had a corrective experience in thetherapy. (Description of the first three general themes, with illus-trative quotes, can be found in Appendix B in the online supple-mental material.)

Evidence of a Corrective Experience

In comparing the interview data with the Penn State definitionof CE, we concluded that Ms. K did “come to understand oraffectively experience an event or relationship in a different orunexpected way” as a result of this therapy. Data reflecting thetheme, resolution of unfinished business from childhood, showedMs. K’s her new understanding of what had occurred in herchildhood. Referring to her mother, Ms. K said, “When I was achild I was forgotten quite often and that made me feel like I didn’tbelong, that I was unwanted, I was on the outside. And seeing thatand that it wasn’t really my fault and putting the blame where itbelonged and then forgiving, which I have a very hard time withforgiveness, actually getting to that point and working through it.”Regarding her deceased father, she explained, “I took the blameoff of my father . . . my mom had left me a lot, so I always feltunworthy, not belonging, uh what I didn’t realize is that I blamedmy father for not correcting my mother or making sure I was safe. . . And my father never, never protected me. I didn’t have eitherone of ’em, so that molded me, and finding that out has alsomolded me into who I am now, where this is the way I am, and thisis why I am, and it’s all right to be angry and it’s all right toforgive.” Likewise, Dr. G indicated that toward the end of treat-ment, Ms. K “was getting out some anger at [her father], likewhere was he? Why didn’t he take her [mother] to task for doingthis?” Ms. K described a sense of surprise at her new feelingstoward her father: “I understand and this is the funny part is, Iunderstand he wasn’t perfect and that I wish he was a stronger manand I still have a little resentment for him . . . and I forgive him andit’s not he’s on a pedestal above everybody else . . . and I doforgive him now and I do believe he forgives me. It’s weird.”

Reflecting the theme more adaptive interpersonal relationships,Ms. K spoke about experiencing a new and different relationshipwith her mother (as well as with other people in her life). Ms. Kwrote, after Session 16, that she was becoming “closer” to hermother. Similarly, Dr G said that Ms. K was “enjoying her moth-er’s company, which never was happening before” and that she“has gone a long way toward repairing the relationship with hermom.”

STDP-Specific Mechanisms of Change

Three general themes in the narrative data were consistent withchange processes in short-term dynamic psychotherapy: gaining

Table 1Transcription Notation

(.5) A pause timed in tenths of a second(.) An untimed short pause� There is no discernible pause between the end of a speaker’s

utterance and the beginning of the next utterance( ) Material in parentheses is inaudible: An extension of preceding sound (one or more colons)Italics Words or parts of words that were uttered with added

emphasisCAPITAL Words were uttered louder than the surrounding talk? A rising inflection. A stopping fall in tone°° Talk between °° is quieter than surrounding talk� � Talk between � � is quicker than surrounding talk[ ] Overlap of talk; brackets are placed by the words overlapped) Rising and falling intonation.hh Inhale

Note. Adapted from Atkinson and Heritage (1984).

353CORRECTIVE EXPERIENCES IN STDP

insight, experiencing of disavowed affect, and confrontation ofcharacter defenses. First, both client and therapist attributed thesuccess of treatment largely to gaining insight, generally in termsof Ms. K’s personality (e.g., “Before I would set the bar so high I’dnever meet it, and I’d keep trying . . . then I’d get overwhelmedand aggravated and anxious”) and specifically in terms of (a)becoming conscious of maladaptive coping mechanisms (“[if]someone pissed me off, I’d dump ’em before they could leave” and“I could literally write ’em off—no ifs, ands or buts”) and (b)understanding her present behavior in light of the past (“I also seemyself projecting my insecurities of being left, ignored and for-gotten to my job and how I feel I am viewed outside of the home”).Ms. K vividly described new insights related to previously uncon-scious family of-origin issues, particularly her intense anger. Dr.G’s interview closely echoed Ms. K’s with regard to this theme,both generally and specifically.

Second, with respect to experiencing disavowed or unconsciousaffect, Dr. G described moments in which Ms. K “would get intouch with this huge sadness or this vicious anger,” which he sawas “pretty profound, transformative moments for her.” He alsomentioned having “the sense that something powerful was hap-pening in the room” when, for example, Ms. K imagined punchingher mother. Likewise, Ms. K explained that, in contrast to her priorbelief that she would be a “bad person” for having “bad thoughts”about other people, she learned in therapy that her rageful feelingswere acceptable so long as she did not act on them: “ . . . you’re notgonna act on it ‘cause you know it’s that wrong and you’reconscious of that but you need to actually imagine it so you get thatrelief.” In her Session 28 questionnaire, Ms. K wrote, “I neverknew I had that much anger in me. I always thought I was apassive, happy go lucky person.”

Third, with respect to confrontation of defenses, Dr. G described“challenging” Ms. K to examine (a) what happened with hermother and her feelings about it and (b) her “idea” about going totherapy to “fix herself” without his help, exemplifying what he sawas “pathological self-reliance.” More colorfully, Ms. K describedher defensiveness by explaining how Dr. G “would keep chippingat that wall.” After Session 16, she wrote, “I believe it’s the ‘gentleshove’ of questions that make me see what I have been trying toignore since childhood.”

Nonspecific Mechanisms of Change

Four themes in the qualitative data reflected factors that arecommon across theoretical approaches: (a) motivation, (b) rapport,(c) safety, and (d) acceptance (e.g., Norcross, 2002). First, aprominent theme in both the client’s and the therapist’s interviewssuggested a dialectic between Ms. K’s motivation versus resistanceto treatment. In terms of motivation to change something specific,Ms. K said, for example, “But now I’m so aware of my feelingsinside that I wanna know what’s causing it, because that way I canfix it.” In terms of general motivation, Ms. K stated, “I alwayslooked forward to coming [to therapy] even though I hated com-ing, but I couldn’t wait to get here and when I was here, I honestlycouldn’t wait to leave. But I needed that . . . I also had a sense ofrelief and a sense of pain at the same time, so it was a double edgedsword. It was . . . it felt good but it also felt like hell sometimes.Sometimes, honestly, as soon as I sat down and started talking Iwanted to get up and leave.” After Session 16, Ms. K wrote, “I

know that talking about things even though most is very uncom-fortable has opened my eyes to why I feel/felt the way I do.”

Likewise, Dr. G noted Ms. K’s strong motivation, explainingthat he initially saw her as “the classic quitter-of-therapy” and“thought she might bolt after she got some symptomatic relief”particularly because “she was very rule bound” and “had allthese injunctions in her head against feeling too much anger orcriticizing mom and dad.” These beliefs proved troublesome intherapy; Dr. G explained that they caused her to get “hung upat moments in the therapy,” but that ultimately “she was able tobreak through.” Dr. G also commented on Ms. K’s “hardwork-ing, finish-the-job mentality” and “work ethic,” which he be-lieved led her to want to finish what she had started. He added,“She seemed genuinely interested in the process once she gotinto it.”

Another change mechanism, mentioned by both parties, wasrapport. Two themes that emerged (only) in Ms. K’s interviewwere safety and acceptance. She referred to Dr. G’s office as her“safe zone,” saying that “his office honest to god was the onlyplace I totally felt safe” and that she “never had a guard up inthere.” Further, she “didn’t have to watch what [she] said and how[she] said it,” could be herself and did not sense any expectationsabout how she had to behave. She saw Dr. G as respectful,accepting, and validating (“I don’t think anything I said shockedhim or was a negative” and “There was no standard bar of whereI had to be”).

Conversation Analysis: Resistance Talk

In Ms. K’s postsession questionnaires, she explained that hertherapist “chipped away at that wall” and used “the ‘gentleshove’ of questions that make me see what I have been tryingto ignore since childhood.” Consistent with her explanation, thesessions had multiple instances of the client and therapistconstructing the client as “resisting” exploration of her emo-tional experience of childhood, particularly relationships withher parents. We examined in depth both explicit and implicitreferences to Ms. K resisting discussing the material deemedclinically relevant and significant.

The review of three videotaped sessions resulted in 17 segmentsthat discussed the client’s resistance to emotional expression; 10representative excerpts are included in this article. (Appendix C inthe online supplemental material contains all 17 segments.) Byexamining the details of the therapy talk in these excerpts, weanalyzed how, on a micro level of discourse, the therapist andclient described and addressed the client’s resistance to exploringpainful relationships with her parents.

The segments are not presented chronologically but are groupedbased on the interactive practices and devices that were used in thefeatured segments. The results of the CA are organized in twosections: resistance and working through. Segments illustrative ofeach phase are presented below. Most resistance segments oc-curred in Session 16, whereas most working through segmentsoccurred in Sessions 24 and 28.

Resistance phase. In segment 1, which occurred only 10seconds into the recording of the session, the therapist used avariety of conversational devices to show the client that talkingabout her “work” (i.e., her job) was an active maneuver away fromthe “real work” of therapy, which required a discussion of her

354 FRIEDLANDER ET AL.

mother. This segment begins with the therapist quoting the client,who had said, “I must really hate my mother”:

Segment 1 (Session 16; min 0:10–0:55)

1. T: I must really hate my mother (1.0) and we spendsome time talking about that

2. (0.6)

3. C: Yeah

4. (0.7)

5. T: U::h and you go back to the work. you know I I beginto [think

6. C: [Safe zone

7. (1.6)

8. T: Ya (2.5) That’s what I think it’s become a safemaneuver that you are coming each

9. (1.5) time to talk about work and then I sa:y we:::llwhere has this come from, and we

10. lead back to your mother, and the next week you comeback and we start all over,

11. you start talking about work as if you don’t know thatyour mother is in the

12. background.

13. C: Uh honestly and that’s the hard part and (0.5) I guessthat’s my (0.5) defense1

14. T: Uh huh

15. (0.5)

16. C: �I don’t�

17. (1.8)

18. T: But it’s almost like you leave it to me (there) (0.8) topull you back into the zone of

19. the real work

20. (1.0)

21. C: Which is my mom

In line 1, the therapist cites the client’s prior speech (“I reallyhate my mother”), implying the reported presence of emotionalintensity. The exploration of the Ms. K’s relationship with hermother is not only “topicalized” (i.e., presented as a relevant andsignificant topic; Vehvilainen, 2003) but is portrayed as somethingshe repeatedly resists exploring further.

Dr. G “scripts” (Edwards, 1994) or describes Ms. K’s resistanceas a recurrent behavior tendency, rather than a singular occurrence,by citing the predictable sequence of events in therapy: talk about

Ms. K’s mother, with the client “each time” returning to discussingher work (lines 1–5 and 8–12). The client’s tendency to resist ispresented as established (“it’s become a safe maneuver,” line 8).The therapist presents the topic of the mother as more relevantthan the topic of Ms. K’s employment (note the added emphasisin “work” and “that” in lines 1 and 5). Later Dr. G uses aconditional clause (“as if you don’t know that your mother is inthe background,” lines 11–12) to suggest that Ms. K pretends toignore the topic despite her recognition of its salience. Dr. Gfurther substantiates his claim about the client’s resistance byimplying that the claim is based on evidence acquired throughrepeated observation (“I begin to think,” line 5). These andother conversational practices allow the therapist to present hisobservations as neutral or factual and to keep the client ac-countable for resisting exploring her relationship with hermother.

The formulation (Heritage & Watson, 1979), or recast of theclient as resistant, is jointly or collaboratively developed. Ms. Kjoins Dr. G in describing her actions in therapy as evidence of hertendency to resist discussing certain topics or issues (lines 6, 13,21). In line 21, the client collaboratively completes the therapist’sprior turn (Lerner, 2004), which allows her to display the commonor shared understanding that she resists talking about the mother.The participants use a range of terms to label the client’s actions intherapy (e.g., “defense,” “safe zone”). Interestingly, Dr. G trans-forms Ms. K’s term “safe zone” into “safe maneuver” (line 8).Casting the client’s actions as “maneuvers” foregrounds heragency and proposes that she is accountable for resisting. Ms. Korients to the issue of accountability by offering an account orjustification that implies that she is having difficulty not resisting(“that’s the hard part,” line 13). Ms. K constructs herself as unableto stop resisting rather than as being unwilling to or lacking desireto do so.

In segment 2, an account is co-constructed regarding the client’sintense “unresolved feelings” about her mother (lines 1–18). As inthe previous segment, the therapist’s interpretation is grounded inMs. K’s prior talk, namely that she is still “badly” affected bysudden (�“WA::M”�) and “overwhelming” emotions (lines 2–4),implying the relevance and importance of exploring these feelingsin therapy.

Segment 2 (Session 16, min 06:58–07:47)

1. T: So there is a lot of anger and a lot of anxietysometimes.

2. C: Oh yeah (2.8). Some days it’s overwhelming somedays it’s (0.9) nonexistent (1.7).

3. And actually I have a couple of nonexistent days (1.0)�and then I’ll be like WA::M�

4. (0.7) and you can feel it starting to build (0.6) [and thenI wake up (.)

5. (0.7) T: [My guess my guess of course is

6. that these unresolved feelings about your mother, andyour family

7. C: are still affecting me �

355CORRECTIVE EXPERIENCES IN STDP

8. T: � are affecting You (0.6) badly.

9. (2.7)

10. C: I know that (0.6) i am still (0.4) affected, (0.9) and Iknow I am still having the

11. anxiety

12. T: Yeah

13. (1.5)

14. C: But I still have that fear of (0.3) going beyond thethreshold

15. T: °No I understand°

16. (1.5)

17. C: Not much scares me but that does (2.9). It’s�kindalike stick me in a room full of

18. spiders

Ms. K confirms the accuracy of Dr. G’s formulation that she is“still affected” by her past by co-completing his formulation (line7). She constructs herself as recognizing (“I know”) that the past isstill prominent in her life (lines 10–11) and that “going beyond thethreshold” (overcoming resistance) is important and relevant forbeing less affected by these feelings. At the same time, shepresents her resistance as a reasonable response. Namely, sheconveys the intensity of her fear by using the metaphor of beingplaced in a room full of spiders (lines 17–18). This metaphorallows her to construct resistance as understandable and justifiable,given that even for a brave person like her (“not much scares me”,line 17), exploring the past is extremely frightening.

Segment 3 (Session 16, min 11:00–11:46)

1. T: . . . And I wonder what you need from me. A push, alittle reassurance (4.7)

2. C: I know you say push and I tense up

3. T: Uh huh. so that’s not it (1.6). Then I can’t really (0.7)I can’t force you to deal

4. C: No

5. T: with this stuff �know� I can’t (0.6) I can push a littlebit at your defenses and say

6. hey here is another laugh but I can’t force you (0.7) todeal with this nor would I

7. want to

In this segment, the therapist develops an account of himself asa gentless or unable to “force” Ms. K to deal with the issue of hermother, implying once again that responsibility rests with theclient. The client’s laughter, labeled as “defense,” is repeatedlypresented by the therapist as a noteworthy observation (“hey here

is another laugh,” line 6). To bring into the client’s conscious herresistance of the topic of her mother, the therapist presents hisinterpretations as the mere observations of an impartial witness,grounding his conclusions in evidence— his citations of the cli-ent’s words and reported actions.

At times, the client “notices” and refers to her own actions asdefenses (segment 4 below, lines 1 and 5), mirroring the therapist’sprior interpretations. At the same time, she continues justifying herrefusal to explore certain experiences by providing an account ofpsychological defenses being powerful and outside of her control(note the use of passive voice in “I am stopped” and the metaphorof “slamming on the breaks”). Overall, Ms. K continuously pres-ents herself as willing (“I would lo:::ve to say ffuck the rules”, line6) yet unable to challenge the defenses or beliefs that prevent herfrom expressing emotions related to her past.

Segment 4 (Session 16, min 23:30–24:05)

1. C: Umm (0.7) there goes the smile

2. (0.6)

3. T: °So what’s under the smile?°

4. (2.5)

5. C: Defe::nce (0.7) tha:t I actually have things I hate inmyself

6. (0.9) and I know that (0.9). I really do hate the fact thatI am so rigid (1.7). I would lo:::ve to be able to

7. say ffuck the rules and (1.6) it just doesn’t matter (0.9).But I get to that point and I

8. am sto:pped (1.0) and it’zz (0.7) it’s kinda like slam-ming on the breaks

9. (.)

10. T: [In a sense though your mother didn’t give you rules(0.7)

11. C: [She didn’t give me any

12. rules

Line 1 in the next segment exemplifies Dr. G’s use of thecandidate answers strategy (Pomerantz, 1988), which speakers useto direct or assist the respondent in providing particular kinds ofanswers or information. In this instance, Ms. K’s selects bothoptions specified by the therapist (lines 3 and 7). Candidate an-swers and yes/no interrogatives constrained the client to respond inspecific ways that were consistent with the therapist’s agenda ofexploring and overcoming resistance.

Segment 5 (Session 28, min 2:50–3:49)

1. T: Do you want to take a look at this? (0.6) or you thinknot.

2. (3.6)

356 FRIEDLANDER ET AL.

3. C: .hh Honestly I don’t (0.5) but I do. (0.8) Cause I knowthat (0.6) if I don’t (1.3) then

4. maybe I’m still gonna have my anxiety (0.5) and I don’twant that (1.0) so:

5. (0.9)

6. T: °Mhmm°

7. C: I wanna say I’m right down the middle.

8. (0.8)

Working through. Subsequent segments illustrate the shiftin the structure of discourse from (a) the therapist “noticing” andproblematizing resistance and the client justifying it, to (b) thetherapist noticing resistance and the client initially disagreeing thatshe is resisting, then engaging in an experiential reflection on herpast. Segment 6 takes place during an imaginal exposure in Ses-sion 24:

Segment 6 (Session 24, min 24:59 – 25:50)

1. C: Still trying ta get her to listen.

2. (0.7)

3. T: Mhmm. Are you angry still?

4. (3.1)

5. C: Not so much angry as annoyed

6. (0.6)

7. T: Annoyed,1but you look so subdued, you don’t lookeither one (1.1). You just look

8. like you’re blocking something.

9. (1.8)

10. C: (Mm) just trying ta (0.9) actually open it up and

11. (0.9)

12. T: (You don’t look)) part[icularly animated andannoy:ed and �

13. C: [(and see)

14. T: � You know (0.8) you just look like you’re squash-ing it all (Does it) feel like that?

15. (2.2)

16. C: No, actually it doesn’t feel like that.

17. T: What does it feel like?

18. (8.2)

19. C: Like I’m right on that edge.

20. (2.4)

21. T: Edge of what?

22. (3.1)

23. C: Of s:creaming at ‘er

The therapist uses his observation of Ms. K’s behavior in thesession (“you just look like”) as evidence of her resistance (lines7–8). His observations imply inconsistency in the client’s verbaland nonverbal presentations and elicit her assessment of the accu-racy of his perceptions (“[(Does it]) feel like that?”). In response,Ms. K asserts her epistemic authority (to know and describe herown experience; Sacks, 1984) by disconfirming Dr. G’s interpre-tations that she is “blocking” or “squashing” her feelings. She thengoes on to make the reference to a felt emotion. To convey itsintensity, she inserts the image of screaming at her mother (line 23)and the metaphor of being “right on the edge” of not being able tocontain her anger (line 19).

In the following imaginal exposure segment, a similar structurewas observed – the client engaging in overt interactional disagree-ment and mitigating the relevance of the therapist’s interpretationthat she is resisting, followed by exploring the relationship withher mother.

Segment 7 (Session 24, min 28:21–30:27)

1. C: It very much is in slow motion.

2. (1.0)

3. T: So what, are you driving with one foot on the break?(3.0) hm?

4. C: No it’s just very hard ta imagine her (1.4) giving mewhat I need

5. (1.2)

6. T: Right [but so you

7. C: [when it goes against(0.5) how she feels.

8. T: Yeah. So you’re- now you’re imagining she’s got herdefenses up, but still it feels

9. like it’s in slow motion (3.8). So this is not a scenewhere she’s: getting it and

10. giving you what you need, it’s a scene where she’sdefensive (0.8). So fine, so

11. imagine that (1.0). But I still feel like you have your footon the break (7.8). Ya

12. think?

13. (2.6)

14. C: N:o, it’s just very hard to imagine it.

15. (0.7)

357CORRECTIVE EXPERIENCES IN STDP

16. T: To imagine her being defensive?

17. (0.7)

18. C: To imagine the whole situation.

19. (0.5)

20. T: Why?

21. (1.3)

22. C: Cause at one point it was relaxing and soothing andnow we’re right back to (1.4)

23. T: ((sniffs))

24. (1.8)

25. C: Basically talking to a wall.

26. (0.9)

27. T: And that’s what happened as a kid, if you were sickor hurt she’d be there and be

28. loving and attentive and then the wall would go upagain.

29. C: °Yeah. °

30. T: As you put up your walls (1.6). and I wonder ifyou’ve got a wall up today too.

31. (22.6)

32. C: I don’t think I have a wall up today. I just can’t see:(5.1) �I can’t see:� (3.0) her

33. outside of either the nurturing or (4.7) the nondefensive(0.8). It’s one or the other

34. with her.

35. (1.3)

36. T: (You mean) nurturing or defensive?

37. C: Yes (2.2). (It’s) (1.4) n::ever (a) (0.9) middle ground,it’s one or the other.

In segment 8, Dr. G and Ms. K engage more extensively inco-constructing some meaningful descriptions of her blocked emo-tions. In this segment Ms. K has just imagined a dialogue with hermother, in which her mother said, “I’ll try.”

Segment 8 (session 24, min 12:42–13:32)

1. C: °Another wall.°

2. (0.4)

3. T: °A:h ha.° (0.4) .hhh But the wall says something bigmight be coming. �

4. C: � (Mm)

5. (0.5)

6. T: Something emotional (0.8). .hhh So she says I’ll try:and then what’s: °(if we)° let’s

7. just gently take that wall down and wha’ do you have

8. (4.5)

9. C: A little relief.

10. (0.6)

11. T: U:h huh (0.9). Well it’s time you give yourself somerelief.

12. (0.7)

13. C: ((sniffs))

14. T: And why is there relief?

15. (2.4)

16. C: Cause I know it’s not just me alone

17. (2.0)

18. T: Wha’ do you mean

19. (2.4)

20. C: I actually ha:ve somebody there (0.7) to count onother than myself �

21. T: � You have a mom (2.2). your (eyes)

22. (0.2)

23. C: Mhmm:

24. (0.5)

25. T: So don’t hold back your feeling, it’s time to (1.7) feelthis relief and realize that you

26. actually do have a mom

Dr. G invites Ms. K to “gently take that wall down” (line 7) andreflect on her emergent experience (“wha’ do you have”). Hespecifically elicits from the client the construction of emotiondiscourse, that is, talk that references emotional states (Edwards,1999), by suggesting that there is “something big . . . somethingemotional” behind the wall. Using the metaphor of a wall andassigning animate qualities to it (“the wall says something bigmight be coming,” line 3) permits taking the therapist (observer)out of the occasion and establishing as factual the existence andsignificance of the material “behind” the wall. By using a buildingmetaphor, the therapist implies that the wall (Ms. K’s defense) canbe assembled and disassembled and establishes the relevance ofovercoming resistance.

358 FRIEDLANDER ET AL.

Segment 9 demonstrates how the therapist presents “venting”anger during Ms. K’s imagined conversation with her mother asimportant and relevant. Dr. G deploys the anger venting/bottlingdichotomy, implying the unhelpfulness of anger bottling (lines5–6). In line 13, he self-corrects, changing “how” the client ventsanger at her mother (the question he already posed in line 5) to“what if” she vented it. The client observably interprets his actionas an invitation to vent, which she accepts (line 15) by “venting.”

Segment 9 (Session 24, min 21:47–22:26)

1. T: .hh and That’s it? D’You Give up?

2. (2.0)

3. C: No I stay angry.

4. (0.7)

5. T: You stay angry? But how do you vent the anger ather? (1.8) Otherwise you’ll just

6. bottle it up and vent it at other peop[le

7. C: [Mm:: you got it.

8. (0.4)

9. T: What?

10. (0.6)

11. C: That’s: exactly it.

12. (0.3)

13. T: Well how (.) what if you vented at her?

14. (17.4)

15. C: Why can’t you stay and let (0.5) me know that myfeelings ar:e (.) of value

Finally, in segment 10, Dr. G directly asks Ms. K when she wasgoing to stop resisting (line 1), implying that she is accountable fordelaying their exploration of the past. Rather than seeking newinformation, wh-questions (when, what) convey negative asser-tions and suggest that there is no adequate account available and,hence, no grounds for the prior action (i.e., the client has nogrounds for resisting).

Segment 10 (Session 28, min 27:32–29:49)

1. T: So when are you gonna take the cap off the bottle?

2. (6.2)

3. C: I’m afraid to?

4. (1.3)

5. T: What’s your fear?

6. (3.0)

7. C: Cause I don’t know what’s gonna come out.

8. (3.3)

9. T: (Well uh) sadness (0.6) (what’s) gonna come out(13.3). what is it that makes you look so sad now?

10. (2.5)

11. C: I’m just thinkin’ about how (1.3) literally if it wasn’tfor my grandma i () (when i was little)

12. (1.3)

13. T: Yeah, you would have been alone (1.4) (). (3.8)1Still you don’t quite let all the sadness come forth,2do you.

14. (0.7)

15. C: No

16. (0.8)

17. T: [What do you-

18. C: [I can feel it

19. (0.7)

20. T: In your chest?

21. C: Yeah

To summarize, throughout the 10 segments, the therapist wasrepeatedly observed (a) explicitly eliciting accounts or reflectionsfrom the client on her resistance (“Why are you holding?”), withMs. K, in the next speaking turn, providing accounts or explana-tions justifying such resistance (“I am afraid”); (b) formulating theclient’s prior talk (i.e., portraying or summarizing), which alloweda moving forward collaboratively by establishing mutually en-dorsed relevant topics and activities (e.g., overcoming resistance,experiencing affect, discussing the client’s mother); (c) continu-ously topicalizing (Vehvilainen, 2003) Ms. K’s avoidance of spe-cific topics or issues, for example, by selectively focusing onparticular aspects of the client’s discourse or behaviors in therapy;(d) scripting (Edwards, 1994) the client’s avoidance as a recurrentoccurrence or tendency; (e) referring to or labeling the client’sbehaviors and talk as “evidence” of her tendency to resist (Veh-vilainen, 2003); (f) agreeing with or confirming Ms. K’s catego-rization of herself and her actions as “resistant”; (g) using meta-phors, vivid images, and descriptive terms (e.g., looking at stuff,wall, boundary, defense, guard, slamming on the breaks, goingbeyond, the room full of spiders) as argumentative resources toadvance certain accounts or versions of events and underminealternative versions (Edwards, 1999); (h) inviting Ms. K to de-scribe emotions or to engage in an imagined dialogue with hermother; and (i) using the candidate answers strategy (Pomerantz,1988) and yes/no interrogatives (Raymond, 2003) to indirectlyelicit the client’s preferences for moving forward in interaction. Atthe same time, the latter two practices constrained the client by

359CORRECTIVE EXPERIENCES IN STDP

implying the domain of legitimate responses and inviting her toendorse, in her response, a specific set of (psychodynamic) pre-suppositions.

Discussion

Based on the results from varied data sources (open-endedquestionnaires, posttreatment interviews, and videotapes), we con-cluded that “Ms. K” did indeed have a corrective experience in thistherapy. Specifically, the interview and questionnaire data withinthe themes resolution of unfinished business from childhood andmore adaptive relationships were consistent with Castonguay andHill’s (2011) theoretically nonspecific definition of corrective ex-perience. That is, Ms. K came to have a different emotional andcognitive experience of her relationships with both parents, espe-cially her mother; by the end of treatment, Ms. K’s relationshipwith her mother had begun to improve. In the therapeutic work shecame to understand a pivotal childhood event (being “left, ignored,and forgotten” in a store by her mother) and experienced rage forthe first time, followed by relief. With respect to her deceasedfather, Ms. K discovered her unconscious anger and profounddisappointment in him for not having protected her from hermother. Later, she forgave him.

On determining that Ms. K did have a corrective experience, weexamined the qualitative themes and the conversation analysis togain a deeper understanding of how the corrective experiencecame about. There were no a priori expectations about the specificfactors that would emerge as most salient for this client. In termsof change processes that are not specific to STDP, Ms. K describedDr. G as respectful, accepting, and validating. She also vividlydescribed finding a sense of safety in the consulting room that sheexperienced nowhere else in her life. Dr. G’s rapport with Ms. Kwas evident in his emotional attunement and attitude toward herneed for deep understanding, as well as in the similarity betweenhis and Ms. K’s independent perspectives on the nature and basisfor therapeutic change.

In addition to these common factors, the change processesdescribed by Ms. K reflected the therapist’s theoretical approach,STDP. In summary, Ms. K learned to control her anger andovercome crippling anxiety by (a) allowing herself to feel angerand sadness more deeply than ever before and (b) achieving newrealizations (i.e., insight) about herself as a person, about herchildhood relations with her parents, and about her current rela-tionships. These results reflect the seven processes that Blagys andHilsenroth (2000) described as distinctive to psychodynamic psy-chotherapy. That is, Ms. K’s therapy focused heavily on thefacilitation of emotional experiencing; on the identification ofrecurrent themes (feeling like “the outsider looking in”); and onexploring her avoidance of distressing thoughts and feelings (ragetoward her mother, disappointment in her father), her past expe-riences (painful childhood events), her fantasies (“punching” hermother), and her interpersonal relations (with family, others, andthe therapist).

Consistent with Diener et al.’s (2007) meta-analysis of psy-chodynamic processes, in which the most empirical support wasfound for the therapeutic facilitation of affect, our conversationanalysis showed how Ms. K’s resistance to emotional expressionwas handled therapeutically. Dr. G’s varied invitations to Ms. K toexpress her experience emotionally did eventually result in a

meaningful exploration and resolution of painful issues stemmingfrom a neglectful childhood. Specifically, in 17 segments from thelast half of treatment, we saw how Ms. K moved over time fromresistance to working through. Using vivid metaphors to describeher resistance (“I still have that fear of going beyond the threshold. . . kinda like stick me in a room full of spiders”), Ms. K was ableto fully experience her rage toward her mother, imagining herselfscreaming at and punching her. Eventually she described a sense ofrelief and a realization about her mother “that I actually havesomebody there to count on other than myself” (segment 8, Ses-sion 24). Then, when she began to tear up, the therapist responded,“You have a mom . . . So don’t hold back your feeling, it’s time tofeel this relief and realize that you actually do have a mom.”

The internal validity of our findings is supported not only byconsistency among the four data sources but also by the congru-ence of the results with the theoretical and empirical literature. Interms of internal consistency, there was remarkable similarity inMs. K’s written description of changes midtreatment, in the twoposttermination interviews, and in the conversation analysis,which showed how the therapist’s “gentle shove of questions” and“chipping away at that wall” (Ms. K’s words) brought aboutsignificant cognitive and emotional change. Interestingly, but notsurprisingly, the therapist had more to say in his interview aboutthe theory-specific change elements, whereas Ms. K had more tosay about the nonspecific factors, for example, motivation andtherapeutic rapport.

In terms of congruence with the client experiencing literature,the changes Ms. K described as a result of treatment reflect thosecited in many previous studies: improved interpersonal functioningand self-esteem, reduced anxiety, greater mastery (Strupp et al.,1969), self-understanding and awareness, relief (Elliott & James,1989), empowerment and personal contact with the therapist(Timulak, 2007). Likewise, the change mechanisms that Ms. Kdescribed in her posttermination interview reflected the “helpfulexperiences” or “impacts” reported by previous researchers: in-volvement with an emotionally present therapist, insight/introspection, greater understanding of the self in relation to oth-ers, catharsis, confidence, relief, feeling understood, and so on(Elliott et al., 1985; Elliott & James, 1989; Orlinsky & Howard,1975; Timulak, 2007).

Specific implications for practice can be derived from the con-versation analysis. First, repeatedly, persistently, and thoroughlyaddressing a client’s resistance to emotional expression can facil-itate the successful resolution of deep emotional distress. Second,therapists need to be not only responsive but also persistent. Inmultiple segments across sessions, Dr. G continuously adjusted hisresponses in light of Ms. K’s feedback on the acceptability of hisideas and proposals. When faced with Ms. K’s resistance, Dr. Gneither forced compliance nor abandoned the pursuit of his psy-chodynamic agenda. Rather, he treated Ms. K’s responses aslegitimate, all the while selectively using the portion of her re-sponse that enabled them to jointly continue in dialogue.

In terms of limitations, first, the extent to which the use ofpsychotropic medication influenced Ms. K’s symptom relief isunknown. However, she was prescribed minimal doses, her com-pliance was spotty, and she discontinued both medications shortlyafter beginning therapy. Second, the interview and questionnairedata were highly subjective; however, to minimize confirmatoryand social desirability bias, different individuals conducted the two

360 FRIEDLANDER ET AL.

posttermination interviews without listening to one another’s au-diotapes. Finally, although client and therapist identified similarcausal mechanisms, there was no independent evaluation of thetherapy’s success.

For this reason, the conversational analysis was a critical aspectof this study. To maximize its meaningfulness, we purposelyanalyzed sessions that preceded the client’s completion of the CEquestionnaires. The rigor of the analysis was ensured through thefollowing procedures: First, extended segments of the participants’responses were displayed alongside the interpretive account toallow readers to evaluate our conclusions. Second, to evaluate theplausibility or trustworthiness (“truth” value) of analytic claims,we engaged in discussions with one another, incorporating feed-back into the final draft of the results (Lincoln & Guba, 1985).Finally, by providing these rich details, we enhanced the transfer-ability of the CA results to other settings (Lincoln & Guba, 1985).

Although the segments that we analyzed showed remarkablesimilarity, the communicative procedures used to present Ms. K asresisting may well be unique to this case. Moreover, because onlya few sessions were examined, the observed conversational prac-tices may not be representative of the entire treatment. The focus,rather, was the in situ (i.e., contextualized and particularized) useof whichever interpretive and interactive practices client and ther-apist selected in order to bring about therapeutic change (ten Have,2004). Thus rather than identifying generalizable linguistic prac-tices, the present analysis shows a variety of ways to achieveemotional expressiveness in the context of STDP (Perakyla, 2004).

Despite these limitations, the ecological validity of our results isnoteworthy. That is, the case was not selected from a manualizedclinical trial but was, rather, psychotherapy as routinely practicedin the community. The therapist was experienced and used aspecific approach in which he had received training, adapting thatapproach over many years to his own personal style. Althoughthere were no adherence checks, observation of the sessions left nodoubt that this was an active, challenging psychodynamic psycho-therapy.

Future researchers might replicate this study with other STDPtherapists or contrast these findings with cases whose outcomeswere less stellar. It would be interesting to discover, for example,whether the nonspecific or the STDP-specific factors are differentor absent in a poor outcome case. It would also be of interest todetermine whether the themes that emerged in this study general-ize beyond STDP, inasmuch as some elements (e.g., confrontationof character defenses, experiencing disavowed affect) are alsotheorized to occur in process-experiential psychotherapy (e.g.,Greenberg, 2002).

The advantage of qualitative research with multiple data sourcesis the opportunity to obtain a rich, nuanced understanding of theexceedingly complex enterprise that is psychotherapy. By privi-leging clients’ voices, we position our results to provide themaximum benefit to those whose opinions matter most.

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Appendix A

Posttermination Interview Protocol

Part 1: Preliminary Questions

1. What were your [the] primary concerns that led you [theclient] to seek this past therapy?

2. Please describe the reason or reasons for ending treatment atthis time.

Part 2: Broad Corrective Experience Questions

3. Are you aware of any differences in who you are [in theclient’s sense of identity] or your outlook on yourself or life [his orher outlook on himself/herself or on life] that you attribute to anexperience or experiences that have occurred since beginning thistherapy?

If possible, please provide a specific example and describe asfully and vividly as possible.

4. Are you aware of any significant shifts or differences in your[the client’s] relationships (e.g., feelings about others, others’views of you [himself/herself], types of interactions) that haveoccurred since beginning this therapy?

If possible, please provide a specific example and describe asfully and vividly as possible.

Part 3: Therapy-Specific Corrective ExperienceQuestions

5. Can you point to any specific times in this therapy or in yourinteractions with your therapist [with the client] that led to mean-ingful differences in your [the client’s] thinking, feeling, behavior,or relationships? This might include, for example, something thatthe therapist [client] did or said, something you said or did, orsome reaction you had [or s/he had].

If possible, please provide a specific example and describe asfully and vividly as possible.

6. Can you point to anything specific that occurred in thistherapy or in your interactions with your therapist [client] that yousee as important and useful now even though, upon reflection, youmay not have at the time?

If possible, please provide a specific example and describe asfully and vividly as possible.

7. Can you point to anything specific that occurred in yourrelationship with your therapist [client] that was unexpected?

If possible, please provide a specific example and describe asfully and vividly as possible.

If example is provided. Do you see this experience (or theseexperiences) as having caused any meaningful shifts or differencesin your [the client’s] thinking, feeling, behavior, or relationships?Please describe fully and vividly.

8. Did you become aware at any time during this therapy of aproblematic pattern (or patterns) in your [the client’s] thoughts,feelings, behaviors, or relationships?

If possible, please provide a specific example and describe asfully and vividly as possible.

If example is provided. Have you become aware of anysignificant shifts, revisions, or differences in that (those) pattern(s)that seem particularly meaningful?

If possible, please provide a specific example and describe asfully and vividly as possible.

Received December 10, 2010Revision received February 23, 2011

Accepted February 28, 2011 �

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