Patient Crying in Psychotherapy: Who Cries andWhy?

Kristen L. Capps,* Katherine Fiori, Anthony S. J. Mullin and Mark J. HilsenrothDerner Institute of Advanced Psychological Studies, Adelphi University, Garden City, NY, USA

Aim: The aim of the present study is to further the understanding of who cries in therapy and therelation of technique with crying behaviour in therapy.Method: Psychological assessment feedback sessions, prior to the initiation of formal therapy for 52patients beginning psychotherapy at a university-based clinic were coded for discrete crying segments.Data about patient characteristics and the process of the session were collected at the time of thesession. Therapist’s interventions were recorded verbatim and independently rated.Results: The number of times a patient cried during their session correlated negatively with global assess-ment of functioning scores and positively with measures of borderline personality disorder pathology aswell as a measure of severity of childhood sexual abuse. Patients’ crying behaviour demonstrated significantnegative correlations with the overall experience of the session (bad/good), smoothness and positivity. Groupdifferences between criers and non-criers reflected these trends as well. No significant correlations or groupdifferences were found with regard to patient-rated or therapist-rated alliance as it relates to crying behaviour.Analysis indicates that therapist intervention prior to patient cryingmost often encouraged the exploration andexpression of difficult affect, new perspectives on key issues or the patient’s fantasies and wishes.Discussion: Our study addresses a significant gap in the clinical literature on crying. Crying behaviourseems to be related to certain clinical variables and has a negative impact on patient experience of thesession in which they cry, although the alliance remained unaffected.Limitations: Small sample, outpatients with mild/moderate psychopathology and graduate traineesprovided therapy. Copyright © 2013 John Wiley & Sons, Ltd.

Key Practitioner Message:• Patients with greater problems in emotional dysregulation, borderline personality disorder symptoms

and greater severity of childhood sexual abuse are more likely to display greater affective intensityduring the beginning of treatment.

• Results suggest that the alliance may remain strong despite patients experiencing a session in whichthey cried as difficult.

• Therapeutic interventions that focus on affect, new understanding of old patterns and patient fantasieswith outpatient clinical populations appeared to be associated with crying in session.

Keywords: crying, affect expression, affect regulation, borderline personality disorder, therapeutic alliance

The lack of systematic investigations of crying as it occurs inthe psychotherapeutic setting is quite surprising.When cry-ing is examined in the psychotherapy literature, it has al-most always occurred in the context of a case study, ratherthan the specific use of a clinical sample to investigate thisissue. The limited work that does exist suggests that howthe therapist responds to the crying patient is importantfor therapeutic outcome and in fact has focused almost ex-clusively on therapists’ attitudes towards responses to clientcrying (Labott, 2001; Nelson, 2008; Van Heukelem, 1979).For example, a recent study by Blume-Marcovici, Stolberg

and Khademi (2013) provides extensive information froma large national sample on therapists crying in psychother-apy. They reported a number of findings regarding thera-pist characteristics that related to their tendency to cry(e.g., that the majority of therapists have cried in sessionwith a patient, and psychodynamically oriented therapistsreported more sessions in which they cried than cogni-tive–behavioural therapists). However, no known work todate has focused on individual differences in and the causesor consequences of patient crying in psychotherapy. Whiletherapist personality characteristics related to crying intherapy sessions and daily life have been identified,normative and pathological aspects of personality inpatients have yet to be explored in relation to their cryingin psychotherapy. Without this information, it is difficultto make informed decisions about how best to approach

*Correspondence to: Kristen L. Capps, M.A., Derner Institute of Ad-vanced Psychological Studies, Adelphi University, Garden City, NY11530-0701, USA.E-mail: capps.kristen@gmail.com

Clinical Psychology and PsychotherapyClin. Psychol. Psychother. (2013)Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1879

Copyright © 2013 John Wiley & Sons, Ltd.

instances of crying in the therapeutic setting. Little empiri-cal evidence exists to help clinicians tailor therapeuticinterventions surrounding crying to meet the needs ofindividual patients.In light of the importance of further understanding patient

crying in psychotherapy, the aims of the present study areseveral and will begin to address significant gaps in theclinical literature. First, what is the frequency of crying in atherapeutic setting, and what is the demographic profile ofthose who cry? Second, what are the associations betweenvarious aspects of global and specific (Axis I and II)pathology with crying in therapy, and how do differentaspects of psychopathology relate to crying? That is, whatare the clinical characteristics most associated with thosepatients who cry in therapy? Third, are there therapistinterventions that may be related to in-session cryingbehaviour? Finally, are there differences in the therapyprocess reported by patients who cry during a sessioncompared with those who do not? That is, how do patientswho cry during a session feel about the session itself, and isit a quantitatively different experience than for those whodo not cry during a session?

Theoretical Background

Historically, affect has been viewed quantitatively in psy-choanalytic theory, referring to the amount of affectcontained within an individual (Rapaport, 1967); there-fore, ‘catharsis’ was seen as necessary to dischargesuppressed affect, which otherwise might result in the for-mation of symptoms (Freud, 1894/1962). Breuer andFreud (1968) called this sich austoben or ‘to cry one-selfout’. Their ‘catharsis’ formulation is especially pertinentto the present study, given its extensive history ininforming therapeutic ideas about crying, and the presentstudy’s focus on crying in the psychotherapy context. In areview of popular press articles spanning 140 years, cryingwas characterized as beneficial in up to 94% of them (Cor-nelius, 1986). In fact, many warned of the dangers of sup-pressing crying. Nelson (2000) concluded that:‘Psychotherapeutic techniques for handling crying, whileseldom discussed directly, generally view it strictly as af-fect discharge, and support it as cathartic or as a good re-lease of feelings or grief (p. 510).’ These beliefs have beenechoed among laypersons and psychotherapists alike inresearch studies. Vingerhoets (2013) reported that in an in-ternational study of individuals from 37 countries, over70% felt that crying improves the way people feel. Amongpsychotherapists, over 70% stated that they had activelyencouraged crying from patients (Trezza, Hastrup, &Kim, 1988). In another study, 88.8% of participantsreported at least some mood improvement following cry-ing (Rottenberg, Bylsma, Wolvin, & Vingerhoets, 2008).

There may be individual differences in the catharticnature of crying. For example, it has been found thatextraversion is related to relief and positive feelingsfollowing crying; in particular, the constructs of excite-ment-seeking (high scores) and depression (low scores)predict feeling better upon crying. In contrast, high scoreson the dutifulness personality facet have been shown topredict feeling worse following crying (De Fruyt, 1997).However, Rottenberg et al. (2008) found no significantrelationship between personality characteristics and moodimprovement following crying. It is also important tonote, however, that Rottenberg and colleagues found that88.8% of participants reported at least some moodimprovement following crying, despite the lack ofsignificant relationships between personality characteris-tics and mood improvement. It will be valuable forclinicians to know if similar findings hold within thetherapeutic context and among a clinical population.A current model of adult crying by Vingerhoets, Cornelius,

Van Heck and Becht (2000) suggested that crying stems frominteractions among a person’s biological factors (e.g.,hormones and physical state), psychosocial factors (e.g.,individual characteristics and personality) and situationalfactors (e.g., social norms and surrounding environment).These authors suggest that a person appraises a givensituation based on these factors, and their correspondingemotional response is then met with instrumental, cognitiveor emotional support. This support, in turn, may alter theirobjective situation or their further appraisal of it. When theindividual’s internal representation is applied to the re-appraisal, their emotional state and further crying behaviouris determined. In this model of crying, a psychotherapysession can be understood as both a situational and arelational factor. Crying in this contextmust be further under-stood, particularly as therapists are tasked with contributingto the behaviour and personality change of the patient to pro-mote more adaptive functioning. In contrast, Nelson (2000)suggested that crying can be understood primarily as anattachment behaviour. That is, crying functions as a relationalmessage, most often with regard to issues of separation andloss, that is shaped socially by others’ reactions to anindividual’s crying. Bothmodels lend a theoretical underpin-ning of the origin and purpose of crying that can guidetherapists in further understanding the specific attributes ofa patient’s crying and possibly its adaptiveness in thepatient’s present life.In addition to theoretical models of crying, a

background in normative crying will benefit cliniciansby placing patient crying in therapy sessions in a contextof crying in daily life. Extensive individual differencesexist in crying proneness and frequency. A wide array ofresearch on crying from several different countries andcultures suggests that in non-clinical populations, womencry more than men (De Fruyt, 1997; Vingerhoets & Becht,2002). In a study spanning 35 countries, it was found that

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on average, women cried 2.7 times in the previous4weeks, as compared with 1.0 time for men. Men alsoreported lower crying tendency and proneness (Becht,Poortinga, & Vingerhoets, 2001). Female gender and neu-roticism have been found to correlate with viewing orusing weeping as a coping mechanism. Those exhibitinggreater emotional stability and extraverts also perceivegreater positive effects from crying (De Fruyt, 1997).Neuroticism and empathy significantly positivelypredicted frequency of crying, whereas anxiety was posi-tively related to perceiving crying as a coping behaviour(De Fruyt, 1997; Rottenberg et al., 2008). Finally, lowercrying proneness has been found to be related to higherreported anhedonia and alexithymia (Rottenberg et al.,2008). With regard to depression, a review of the literaturefound that while increased crying is generally consideredto be a symptom of depressed mood, the empiricalevidence for this relationship is lacking. Similarly, thewidely held claim that severely depressed individualsbecome unable to cry has not been sufficiently examined(Vingerhoets, Rottenberg, Cevaal, & Nelson, 2007). Amongindividuals with borderline personality disorder, the oppo-site has often been found; these individuals are frequentlyunderstood to experience emotional dysregulation, whichcan often indicate amore expansive style of affective expres-sion. In particular, Borderline Personality Disorder featureshave been associated with a history of trauma or childhoodsexual abuse (Bornovalova et al., 2013; Coifman, Berenson,Rafaeli, & Downey, 2012; Zodan, Hilsenroth, Charmas,Goldman, & Bornstein, 2013). Overall, the best predictorsof weeping frequency were found to be female gender andincreased feelings of vulnerability (De Fruyt, 1997).The purpose of the present study is to further the under-

standing of patient crying in psychotherapy to promoteindividualized and effective therapeutic intervention. Wewill accomplish this by investigating the individual andpersonality characteristics of patients who cry in therapy,the therapeutic interventions surrounding crying episodesand patients’ experience of having cried in therapy.

METHOD

Participants

The participants in the study (n= 52) were all patientsadmitted to a Psychodynamic Psychotherapy TreatmentTeam at a university-based community outpatient clinicthat serves students, staff and the community (Hilsenroth,2007). Cases were assigned to treatment practica andclinicians in an ecologically valid manner based on realworld issues regarding aspects of clinician availability,caseload etc. Moreover, patients were accepted into treat-ment regardless of disorder or co-morbidity. In thesample, 39 (75%) patients were female and 13 (25%) were

male. The mean age for this sample was 28.43 (standarddeviation [SD] = 11.46). Only individuals 18 years or olderwere included, with a range from 18 to 65. Table 1displays demographic information, as well as the distribu-tion of patients’ primary Axis I and II diagnoses for theentire sample in accordance with the Diagnostic andStatistical Manual of Mental Disorders, Fourth EditionText Revision (DSM-IV-TR) (DSM-IV-TR; AmericanPsychiatric Association, 2000; based on the psychologicalassessment process described below). All patients in thisstudy received a DSM-IV-TR Axis I diagnosis. For thesample in the present study, 30 (58%) of the patientsreceived an Axis II disorder, and 13 (25%) were assessedto have subclinical but prominent Axis II traits or features(Cluster A= 4 [18%], Cluster B = 18 [35%] and ClusterC= 21 [40%]). In sum, this sample consisted of primarilymood disordered patients with relational problemsmanifested in either Axis II personality disorders, orsubclinical traits/features of Axis II personality disorders,generally in the mild to moderate range of psychopathol-ogy (see Table 1).

TherapistsClinicians in the study were 19 advanced doctoral stu-

dents (nine male and 10 female) enrolled in an AmericanPsychological Association approved Clinical PsychologyPh.D. programme. Each clinician received a minimum of3.5 hours of supervision per week (1.5 hours of individualand 2hours of group) on the Therapeutic Model of Assess-ment (TMA, Finn & Tonsager, 1997; Hilsenroth, 2007),clinical interventions, provision of collaborative feedbackto the patient, psychodynamic theory and review ofvideotaped case material. Individual and group supervi-sion focused heavily on the review of videotaped casematerial and technical interventions. All clinicians weretrained in psychodynamic psychotherapy using guidelinesdelineated by Book (1998), Luborsky (1984), McCulloughand colleagues (2003) andWachtel (1993), aswell as selectedreadings on psychological assessment, psychodynamictheory and psychodynamic psychotherapy (for a moredetailed description of this training process, see Hilsenroth,DeFife, Blagys, & Ackerman, 2006).

TreatmentPatients first received a psychological evaluation by their

therapist using the TMA (Finn and Tonsager, 1997;Hilsenroth, 2007). The TMA used in this study consistedof four steps conducted over threemeetings between the pa-tient and clinician and one patient appointment to completea battery of self-report measures. The three meetingsincluded (1) a semi-structured diagnostic interview (Westen& Muderrisoglu, 2003, 2006), (2) interview follow-up and(3) a collaborative feedback session, which is the focus ofthe present study. During the collaborative feedback

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session, there is an emphasis on prominent interpersonal orintrapersonal themes derived from the assessment results,the patient–therapist interaction, factors that contribute tothe maintenance of life problems and an opportunity to ex-plore these new understandings and apply them to theircurrent problems in living. The patient and clinician also re-view a socialization interview developed by Luborsky(1984) on what to expect in psychodynamic psychotherapy,the patient’s and clinician’s roles during formal treatmentand the relational focus of the therapeutic process. It alsonotifies the patient that he or she may become aware of is-sues that were not known before the start of psychotherapyand outlines potential outcomes (both positive and nega-tive) of this new insight. Finally, the clinician and patientwork together to develop treatment goals and negotiatean explicit treatment frame (i.e., scheduling session times,frequency of treatment session(s), missed sessions and pay-ment plan). In all cases, the clinician who carried out thepsychological assessment was also the clinician whoconducted the formal psychotherapy sessions.

Treatment goals are first explored during the psycho-logical assessment feedback session, at the end of theTMA procedure prior to the initiation of formal therapy,and a formal treatment plan is reviewed with each patientearly in the course of psychotherapy that is subsequentlyreviewed at regular intervals for changes, additions ordeletions. All sessions of these treatments were videotaped,not just the sessions during which ratings were completed.

Patient process and independent technique ratings for thisstudy were collected at the same point in time.

Measures

The data examined for the present study include evalua-tion of crying behaviour, patient characteristics, measuresof psychotherapy process and patient experience ofsessions. Assessment of crying behaviour was performedthrough the examination of videotapes of the patient’sTMA feedback session.

Crying-related Coping Behaviour CategoriesFor each session, the presence or absence of crying was

determined, and defined as “tears in one’s eyes due toemotional reasons (Vingerhoets & Cornelius, 2001).” Eachcrying episode was also coded using Znoj’s method (Znoj,1997), which includes observational categories to classifybehaviours meant to conceal feeling states. The behavioursidentified by this method were recorded in the presentstudy because of their usefulness in providing an empiri-cally validated measure for identifying crying; however,the present study focuses only on the agreement of ratersif crying was present in the session. In particular, behav-iours listed in the measure as indicative of crying includedself-care, blowing the nose, wiping the eyes, hiding the faceand forcing the eyes shut, all of which Znoj proposes may

Table 1. Descriptive information of the sample

Demographic variable Total (N=52) No cry (n=42) Cry (n= 10)

GenderMale 13 (25%) 12 (29%) 1 (10%)Female 39 (75%) 30 (71%) 9 (90%)Mean age (years) (and SD) 28.43 (11.46) 26.8 (10.9) 32.8 (11.4)Marital statusSingle 41 (79%) 33 (78%) 8 (80%)Married 8 (15%) 7 (17%) 1 (10%)Divorced 3 (6%) 2 ( 5%) 1 (10%)Primary Axis I diagnosisAdjustment disorder 6 (12%) 5 (12%) 1 (10%)Anxiety disorder 11 (21%) 8 (19%) 3 (30%)Mood disorder 23 (44%) 20 (48%) 3 (30%)Eating disorder 3 (6%) 1 (2%) 2 (20%)Impulse disorder 1 (2%) 1 (2%) 0V code relational problem 8 (15%) 7 (17%) 1 (10%)Axis II diagnosis 30 (58%) 22 (52%) 8 (80%)Axis II traits/features 13 (25%) 11 (26%) 2 (20%)Axis II clusterCluster A 4 (8%) 4 (10%) 0Cluster B 18 (35%) 14 (33%) 4 (40%)Cluster C 21 (40%) 15 (36%) 6 (60%)Axis VMean intake GAF (and SD) 59.4 (5.9) 60 (5.7) 57 (4.7)

Note: All group comparisons were not significant, p> 0.05.SD= standard deviation. GAF=global assessment of functioning.

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have the intention of diminishing affect and reducing thelikelihood of crying. Body movements, micro-expressionsand vocal indicators are also interpreted as attempts to con-trol underlying emotion. In total, 12 categories of behav-iours were assessed. Inter-rater reliability in the Znojstudy was found to be excellent, with Kappa=0.75.

Additional aspects of crying behaviour were rated aswell. The presence or absence of crying was determinedto distinguish the ‘criers’ from the ‘non-criers’. Forsessions in which crying occurred, the number of discreetcrying episodes was determined using Znoj’s behaviourindicators as a guide for identifying when crying beganand ceased. The content of the crying episode was alsorecorded using the rater ’s interpretation of the theme,event or emotion being discussed at the time of crying.

Global Assessment of FunctioningPatients were assigned a 0-100 rating by their clinician, on

which higher ratings indicate healthier functioning. Theglobal assessment of functioning (GAF) measures apatient’s overall level of global symptomatic distress on acontinuum of illness-health. Low scores on the GAF (1–20)are indicative of individuals who are at risk for hurtingthemselves, incapable of maintaining minimal personalhygiene or experiencing severe disruption in their abilityto communicate with others (e.g., largely incoherent ormute). High scores (91–100) reflect individuals free ofsymptoms and functioning well in a variety of life domains(Jones, Thornicroft, Coffey, & Dunn, 1995; AmericanPsychiatric Association [DSM-IV-TR], 2000). GAF ratingsfor the current sample were in the excellent range, with aone-way random effects model intraclass correlation coeffi-cient (ICC) of 0.88.

Personality Disorder IndexThe Personality Disorder Index (PDI) is a dimensional

classification of DSM-IVAxis II personality pathology thatprovides ratings on a 0-1-2 scale for the presence of apersonality disorder (2), the presence of subclinical features(1) and no personality disorder (0). The subclinical featuresdimension accounts for the presence of personality dysfunc-tion that meets some, but not all, diagnostic criteria for agiven Axis II disorder. In the current study, borderlinepersonality disorder diagnosis (2) and features (1) were alsoused. Hilsenroth et al. (2000) found that the PDI was associ-ated with clinician-rated global distress, global social andoccupational functioning and global relational functioning(Peters, Hilsenroth, Eudell-Simmons, Blagys, & Handler,2006). One-way random effects model ICC in the currentsample for the PDI was in the excellent range for Axis II Di-mensional features, 0.92, and in the good range for border-line personality disorder dimensional features, 0.74.

Shedler–Westen Assessment Procedure PrototypeThe Shedler–Westen assessment procedure (SWAP) is a

disorder classification system that uses prototypes ofpersonality disorders empirically derived from dataprovided by a large national sample of experienced clini-cians who used a 200-item Q-sort instrument (SWAP-200)to describe a specific personality disordered patient in theircare. A statistical procedure Q factor analysis was thenapplied to the data to identify empirically distinct diagnos-tic groupings (Shedler & Westen, 1998; Westen & Shedler,1999a,1999b). The procedure generated seven primary diag-noses: dysphoric, antisocial, schizoid, paranoid, histrionic,obsessional and narcissistic. The dysphoric diagnosisincluded five subtypes: avoidant, high-functioning depres-sive, emotionally dysregulated (borderline) and hostile-oppositional (a variant of passive-aggressive personalitydisorder). Paragraph-long prototypes of each diagnosiswere then created by combining the most empiricallydescriptive criteria (Westen, Shedler, & Bradley, 2006) andfunctionally grouping thematically similar items for easeof clinical use. The focus of the present study is on theborderline-dysregulated prototype, rated on a 1–5 scale(1 =no or little match; 2= some match; 3=moderate match,significant subthreshold features; 4 = good match, hasdisorder; and 5=very good match, exemplifies disorder),on which raters demonstrated excellent reliability with anICC of 0.81.

Abuse Dimension InventoryThe adult patients’ experience of childhood sexual abuse

was measured using the abuse dimensions inventory(ADI) (Chaffin, Wherry, Newlin, Crutchfield, & Dykman,1997). It was developed to assess characteristics andseverity of childhood abuse. The sexual abuse rating scalecatalogues forms of abuse ranging in severity from 0 (none)to 12 (ritual abuse or sexualized torture). Inter-rater reliabil-ity for the present sample was 0.99, in the excellent range.The ADI was used in the current study to classify partici-pants as having experienced childhood sexual abuse ornot and to assess abuse severity. If patients reported morethan one incident of abuse, clinicians and external raterswere instructed to use the numerical value representingthe most severe behaviour experience as their ADI score.

Session Evaluation QuestionnaireThe Session Evaluation Questionnaire (SEQ) (Stiles,

1980; Stiles & Snow, 1984; Stiles et al., 1994) consists of24 bipolar adjective scales rated from 1 (e.g., weak) to 7(e.g., powerful). It is separated into two sections, eachconsisting of 12 bipolar scales. The first section of themeasure is prefaced by the stem ‘This session was . . .’and consists of two indices, identified as depth (power-ful/weak, valuable/worthless, deep/shallow, full/emptyand special/ordinary) and smoothness (smooth/rough,

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comfortable/uncomfortable, easy/difficult, pleasant/un-pleasant and relaxed/tense). The second section isprefaced by the stem ‘Right now I feel . . .’ and iscomprised of two dominant post-session mood indices,positivity (happy/sad, confident/afraid, pleased/angry, def-inite/uncertain, friendly/unfriendly) and arousal (aroused/quiet, fast/slow, energetic/peaceful, moving/still, excited/calm). An additional index, ‘This session was . . . Bad/Good’(scored 1–7; higher scores reflect a more positive rating), isdesigned to measure a patient’s global impression of thesession. The present study includes only patient, nottherapist, ratings of session quality. Previous researchhas found alphas ranging from 0.74 to 0.91 for these fourSEQ subscales (depth, smoothness, positivity and arousal)using a subset of the current participants (Ackerman,Hilsenroth, Baity, & Blagys, 2000).

Combined Alliance Short Form-Patient VersionThe combined alliance short form-patient version

(CASF-P; Hatcher & Barends, 1996) is a patient-rated alli-ance measure created from a factor analysis of the re-sponses of 231 outpatients at a university-basedcommunity clinic from three widely used measures of alli-ance. The CASF-P consists of 20 items rated on a seven-point Likert scale from 1 (never) to 7 (always). The itemsare divided into four subscales with five items each: Con-fident Collaboration (e.g., ‘What I am doing in therapygives me new ways of looking at my problems.’), Goalsand Tasks (e.g., ‘My therapist and I are working towardmutually agreed upon goals’), Bond (e.g., ‘My therapistand I trust each other.’) and Idealized Relationship (e.g.,‘How much do you disagree with your therapist aboutwhat issues are most important to work on during thesesessions?’ reverse scored). Previous research has found co-efficient alphas ranging from 0.84 to 0.91 for the subscalesand 0.93 for the total scale using a subset of the currentparticipants (Ackerman et al., 2000).

Working Alliance Inventory-Therapist VersionThe working alliance inventory-therapist version (WAI-T;

Horvath & Greenberg, 1986, 1989) is a therapist-ratedalliance measure. The total scale score for the WAI-T usedin this study was derived from a recent psychometricadaptation (Hatcher, 1999) using responses from twosamples. The first was a national sample consisting of prac-ticing therapists’ ratings on one patient from their currentpractice (n=251). The second was a clinical sampleconsisting of 63 therapists who completed ratings on 259different patients. Previous research has found alphasranging from 0.75 to 0.86 (Hatcher, 1999) andwhen examin-ing a subset of the current participants, coefficients alphasrange from 0.74 to 0.91 (Clemence et al., 2005). Ratings onthe WAI-T are reported on the same seven-point scale asdescribed for the CASF-P, ranging from 1 (never) to 7 (always).

Comparative Psychotherapy Process ScaleThe Comparative Psychotherapy Process Scale (CPPS) is

a brief descriptive measure designed to assess therapistactivity and techniques used and occurring during thetherapeutic hour. It is based upon the findings of twoempirical reviews of the comparative psychotherapyprocess literature (Blagys & Hilsenroth, 2000, 2002). Fromthese reviews, a list of interventions was developed fromthe empirical literature, which represents characteristicfeatures of psychodynamic–interpersonal (PI; definedbroadly to include psychodynamic, PI and interpersonaltherapies) and cognitive–behavioural (CB; definedbroadly to include cognitive, CB and behaviouraltherapies) treatments. The measure consists of 20 ran-domly ordered techniques (e.g., The therapist encouragesthe exploration of feelings regarded by the patient asuncomfortable; The therapist focuses discussion on thepatient’s irrational or illogical belief system; The therapistaddresses the patient’s avoidance of important topics andshifts in mood; The therapist teaches the patient specifictechniques for coping with symptoms) rated on aseven-point Likert scale ranging from 0 (‘not at allcharacteristic’) to 6 (‘extremely characteristic’). The CPPSmay be completed by a patient (P), therapist (T), or anexternal rater (ER). Ten statements are characteristic of PIinterventions, and 10 statements are characteristic of CBinterventions. These interventions can then be organizedinto two scales: one measuring PI features (CPPS-PI) andone measuring CB features (CPPS-CB). The reliabilityand clinical validity of the CPPS has been well established(Hilsenroth, Ackerman, & Blagys, 2001; Hilsenroth,Ackerman, Blagys, Baity, & Mooney, 2003; Hilsenroth,Blagys, Ackerman, Bonge, & Blais, 2005; Hilsenroth et al.,2006; Stein, Pesale, Slavin, & Hilsenroth, 2010; Thompson-Brenner & Westen, 2005; Westen et al., 2004).

Procedure

Participants in the study completed a standard intakeinterview and psychological assessment as part of thetreatment protocol. Patients assigned to therapists wereasked to sign a consent form to videotape each session.Patients who consented were given measures to completeafter the feedback session and were informed bothverbally and in writing on these forms that their therapistwould not have access to their responses. As the presentstudy is archival, ratings of crying episodes wereconducted using only videotape footage.Two advanced graduate students who had completed

training rated the therapy feedback session for the presenceor absence of crying behaviours from the patient, using theindicators identified by Znoj (Znoj, 1997). In addition, theseraters independently coded the number of times a cryingevent occurred, the start time, duration and end time of

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each event, as well as the verbatim therapist interventionprior to the crying event. Subsequently, the inter-raterreliability of crying events between the independent raterswas determined. The verbatim therapist statements werethen transcribed and presented in a randomized order to asecond pair of independent raters who coded the interven-tions utilizing the CPPS. Theywere blind to all other aspectsof the session, such as therapist and patient identity, processratings, presence and intensity of crying. Subsequent inter-rater reliability between these independent raters was forthe CPPS was excellent (i.e., ICC> 0.74; Table 4).

RESULTS

The results that follow are based on two independentraters’ coding of patient crying events during the psycho-logical assessment feedback session, at the end of theTMA procedure prior to the initiation of formal therapy,on which they achieved excellent inter-rater reliability(ICC=0.96). Of the 52 patients in the study, 10 cried(19%). Those who cried were patients of seven of the 19therapists involved in the study; three of these therapistswere male and four female. Three of the therapists hadtwo patients who cried and four of the therapists hadone patient who cried.

Who Cries in Therapy?

Of the 10 patients who cried in our sample, nine (90%)were female, and one (10%) was male (χ2=1.49(1),p= 0.22), which is consistent with findings that on average,American women report almost five times as manyinstances of crying per month compared with Americanmen (Becht, Poortinga, & Vingerhoets, 2001). The meanage of the criers was 32.8 (SD=11.4), compared with 26.8(SD=10.9) for non-criers (t(50) = 1.54, p=0.13). Eight (80%)were single, one (10%) was married, and one (10%) wasdivorced (χ2 = 0.62(2), p=0.73). With regard to diagnosis,criers and non-criers alike met criteria for a number of AxisI Disorders. Most notably, eight patients (80%) met criteriafor an Axis II Personality disorder, and two (20%) exhibited

Axis II traits or features, compared with 22 (52%) of thenon-criers meeting criteria for an Axis II diagnosis, and 11(26%) exhibiting Axis II traits or features (combinedχ2 = 0.65(1), p=0.42). OnAxis V, themean intakeGAFswere57 (SD=4.7) and 60 (SD=5.7) for criers and non-criers,respectively (t(50) =�1.5, p=0.13). Though many of thesegroup differences resemble those found in laboratorystudies of crying, none from the current study werestatistically significant. Demographic information for criersand non-criers can be found in Table 1.

What are the Clinical Characteristics of Patients WhoCry More?

To further investigate the role of individual differences incrying in psychotherapy, the relationship between individ-ual characteristics and number of crying events was deter-mined (Table 2). Results are based on all individuals in thesample (N=52). GAF scores were significantly negativelycorrelated with number of crying events (r=�0.30,p< 0.05), such that those patients with a higher level ofpersonal, occupational and social functioning tended tocry fewer times in a given session. There were significantpositive correlations between number of crying events andthe borderline personality disorder dimensional classifi-cations of the (r=0.48, p< 0.001), the SWAP emotionaldysregulated prototype score (r=0.34, p< 0.01) and theADI ratings of childhood sexual abuse (r=0.33, p< 0.05).The more features of a borderline personality disorder diag-nosis and emotional dysregulation a person exhibited or thehigher the severity of childhood sexual abuse, the moretimes the patient tended to cry in their psychotherapy ses-sion. The correlation betweenAxis II Dimensional diagnosis(PDI) and number of crying events was not significant(r=0.22, p=0.12).

How did the Patients who Cried Rate the Process oftheir TMA Feedback Session?

The number of crying events by a patient in the session wascorrelated with his or her ratings of the session experience(Table 3; N=52). Significant negative correlations were

Table 2. Independent clinical ratings of pre-treatment characteristics and crying events in the feedback session: descriptive statistics,reliability, correlation coefficient and significance

Sample characteristic variable Mean and (standard deviation) Reliability # Crying events: feedback session r(p)

GAF (0–100) M=59.4 (5.91) ICC= 0.88 �0.30 (0.03)Axis II dimensional (0-1-2) M=1.43 (0.77) ICC= 0.92 0.22 (0.12)BPD dimensional (0-1-2) M=0.39 (0.71) ICC= 0.74 0.48 (0.0003)SWAP emotional dysregulated prototype (1–5) M=2.15 (0.88) ICC= 0.81 0.34 (0.01)Abuse dimension inventory (0–12) M=1.7 (3.14) ICC= 0.99 0.33 (0.02)

Note: N= 52.GAF=global assessment of functioning. BPD=borderline personality disorder. SWAP=Shedler–Westen assessment procedure.

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found with three of the five SEQ indices: the patient’s expe-rience of the session, from bad to good (r=�0.44, p< 0.001,N=52), the smoothness of the session (r=�0.47, p< 0.001,N=52) and the patient’s perceived positivity of the session(r=�0.33, p< 0.05,N=52). These significant negative corre-lations suggest that the more a patient cries during a ses-sion, the more difficult and negatively they experience thesession. No significant correlations were found betweennumber of crying events and the patient’s perceived depthof or arousal during the session. Consistent with the correla-tional findings, significant differences were found betweencriers and non-criers on some of the SEQ variables (Table 3).

In particular, patients who cried rated the session signifi-cantly lower on an index of bad to good (t(50) =�2.67p=0.01), less smooth (t(50) = -2.17, p=0.04) and a trend,which approached significance was found in the differencesbetween criers and non-criers on a scale of perceivedpositivity of the session (t(50) =�1.79, p=0.08).To further investigate the impact of the patient’s having

cried in the psychotherapy session on the therapeutic rela-tionship, the correlation between alliance and number ofcrying events was examined. No significant correlationswere found between either patient-rated or therapist-rated alliance and number of crying events, indicating that

Table 3. Descriptive statistics and comparison between criers and non-criers on psychotherapy process variable as well as therelationship of these variables with number of crying events

Feedback session process variable Means and differences # Crying events: feedback session r(p)

Session Evaluation Questionnaire (SEQ; 1–7)Bad–Good �0.44 (0.001)Overall mean: 6.46 (0.69)Mean differencesCry: M=6.0 (0.94)No cry: M= 6.6 (0.54) t=�2.67 p=0.01

Depth 0.07 (0.65)Overall mean: 5.55 (0.85)Mean differencesCry: M=5.6 (0.71)No cry: M= 5.6 (0.89) t=0.03, p=0.98

Smoothness �0.47 (0.0005)Overall mean: 5.22 (1.01)Mean differencesCry: M=4.6 (1.2)No cry: M= 5.4 (0.90) t=�2.17, p= 0.04

Positivity �0.33 (0.02)Overall mean: 5.21 (0.86)Mean differencesCry: M=4.8 (0.58)No cry: M= 5.3 (0.87) t=�1.79, p= 0.08

Arousal 0.12 (0.42)Overall mean: 3.86 (0.97)Mean differencesCry: M=3.7 (0.92)No cry: M= 4.1 (0.85) t=1.21, p=0.23

Patient-rated alliance (CASF; 1–7) 0.00 (0.96)Overall mean: 6.12 (0.60)Mean differencesCry: M=6.1 (0.66)No cry: M= 6.1 (0.61) t=�0.13 p=0.89

Therapist-rated alliance (WAI-T; 1–7) �0.13 (0.37)Overall mean: 5.78 (0.46)Mean differencesCry: M=5.8 (0.44)No cry: M= 5.8 (0.47) t=0.03 p= 0.98

Note: N= 52.SEQ=Session Evaluation Questionnaire. CASF= combined alliance short form. WAI-T =working alliance inventory-therapist version.

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the therapeutic alliance did not vary in relation to the pa-tient’s crying. Additionally, there were no significant be-tween-group differences in those who cried during theirsession and those who did not on patient ratings of the al-liance (t(50) =�0.13, p= 0.89); M= 6.1 (SD=0.66) for criersand M=6.1 (SD=0.61) for non-criers. No significantgroup differences were found on therapist ratings of thealliance either (t(50) = 0.03, p= 0.98); M=5.8 (SD= 0.44)for sessions in which a patient cried and M=5.8 (SD=0.47) for sessions without crying.

What Role do Techniques Play?

Each crying eventwas also analysed to identify the therapist’sintervention immediately preceding the patient’s crying. Thestatements were coded for type of intervention by two inde-pendent raters who had achieved excellent reliability (ICC0.75) using theCPPS coding systemprior to the current study.Any inconsistencies were resolved by a third expert indepen-dent rater. Twenty-seven separate crying events were identi-fied. Of the 20 possible therapist interventions (Methodsection), five occurred 15% of the time or more, ranging from15–60% (Table 4). The most frequently occurring interven-tions preceding the patient crying event were: #8-Encouragespatient to experience/express feelings (16 crying events, 60%),#13-Suggests alternative understanding not previously recog-nized by the patient (11 crying events, 41%), #1-Encouragesexploration of uncomfortable feelings (seven crying events,26%), #19-Focuses onwishes, fantasies, dreams or earlymem-ories (seven crying events, 26%), #10-Addresses avoidance orshifts in mood (four crying events, 15%). Note that multipleintervention codes can be used for the same statement;intervention #1 and #8 typically co-occurred given their simi-lar focus on promoting expression and depth of affect. Inter-estingly, 23 (85%) of the 27 crying events includedintervention #8, #13 or #19. Please see Table 5 for examplesof these therapist interventions.

Discussion

This study sought to establish the groundwork for address-ing gaps in the clinical literature on crying in the therapeutic

context. Through the independent coding of videotapedpsychological assessment feedback sessions, examiningthe therapist’s interventions occurring just prior to thesecrying events, and analysing measures of the quality ofthe session as well as patient characteristics, significantinsight was gained about the characteristics of those whocry in psychotherapy and the therapeutic conditionssurrounding instances of crying. In particular, similar tonon-clinical samples, women cried more than men.Additionally, individuals with lower global functioning, ahigher degree of emotional dysregulation and borderlinepersonality disorder symptoms, as well as more severehistories of childhood sexual abuse cried more frequently.The findings that borderline personality disorder pa-

thology, problems with emotional modulation, and a his-tory of childhood sexual abuse are related to higher ratesof crying in psychotherapy is consistent with the literatureon borderline personality disorder, which points to an in-creased rate of childhood sexual abuse in these patients’history (Bornovalova et al., 2013). In addition, it is oftenunderstood to be a disorder of affect regulation (Coifmanet al., 2012; Zodan et al., 2013). If borderline personalitydisorder is understood to include problems with affectregulation, finding that these individuals tend to cry morein therapy sessions may have important potential implica-tions for clinical practice.Regarding how patients experienced sessions in which

they cried, significant negative correlations were foundbetween the number of crying events and three of the fiveindices of session experience, including smoothness, posi-tivity and overall ratings of bad to good for the session.These same three types of experiences also evidencedsubstantial between-group differences between thosepatients who cried and did not cry in the feedback session.Therefore, it can be concluded that patients generallyexperienced crying as related to feeling that the sessionwas more difficult and problematic for them. However, itappears that despite these challenging sessions, the alliancebetween patient and therapist remained high. That is, thetherapeutic alliance was unaffected by crying as there wereno significant associations between number of crying eventsand patient or clinician ratings of alliance, and no significantdifferences between thosewho cried and thosewho did not.

Table 4. Frequency of therapist interventions immediately prior to patient crying segment

Item # % ICC

#8 Encourages patient to experience/express feelings 16 60 0.99#13 Suggests alternative understanding not previously recognized by patient 11 41 0.84#19 Focuses on wishes, fantasies, dreams and early memories 7 26 0.94#1 Encourages exploration of uncomfortable feelings 7 26 0.80#10 Addresses avoidance or shifts in mood 4 15 0.77

Note: n= 27 crying segments.Only those therapist interventions occurring 15% of time or more are shown.

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This seems to suggest that despite having a difficult session,which a patient may not have experienced positively, theirconnection to the therapist remained strong. Although wecannot postulate on the directional nature of this relation-ship, our findings do support prior clinical and empiricalwork, which suggests that patients can experienceemotionally challenging, or even painful, sessions and stillmaintain a strong therapeutic bond (Safran & Muran,2000; Safran, Muran, & Eubanks-Carter, 2011). In otherwords, difficult emotional sessions are not necessarilyrelated to difficult treatment relationships.When we examined the therapist interventions that

most frequently preceded crying events, they oftenencouraged the patient to explore, experience and expressuncomfortable feelings (positive or negative), to explorealternative understandings not previously recognized by

the patient (i.e., interpretation) as well as wishes and fan-tasies, and addressed avoidance or shifts in mood. Exam-ples of these interventions from actual patient sessions canbe found in Table 5. Many of the interventions focused onpromoting the experience and intensity of affect, which isconsistent with the catharsis model of crying (Diener,Hilsenroth, & Weinberger, 2007; Ulvenes et al., 2012).Perhaps the therapists were working under the commonlyheld theoretical assumption that crying is a positivedischarge of affect (Freud, 1894/1962) and thereforebeneficial to the patient (Cornelius, 1986). Upon sensinga heightening in affect preceding crying, their interventionsmay have encouraged such release by exploring the feelingsregarded as uncomfortable by the patient. Therapy withthese patients also often focused on integrating new informa-tion into old affective-relational schemas (Connolly Gibbons

Table 5. Example of therapist interventions immediately preceding the crying segment

Intervention type Therapist intervention

#8 Encourages patient to experience/express feelings ‘How are you feeling now’; ‘Tell me about that feeling’‘And as you were saying that a moment ago, what did it feel like?’

#1 Encourages exploration of uncomfortable feelings ‘From what we’ve talked about, what stands out to me is,is a lot of anger on your part. [patient nods] You agree?Okay, it seems that sometimes you get very frustratedand very angry about things, and it really tends toupset your life, it really tends to overwhelm you at times.It’s one of the primary things that I’ve heard you talk aboutor seen you suffer from. Basically, that you’ve got a lot of bottledup anger that you haven’t been able to express.’I wonder what it might feel like to let some of that anger out in here?

#10 Addresses avoidance or shifts in mood ‘Something happened a moment ago that made your thoughtsget a little confused.Do you know if that topic is something that cause you anxiety, thatmade you kind of muddle your thoughts a little… sometimes thathappens when you start to feel anxious about something,and I’m wondering if there was something in what you weretalking about that made you feel anxious.’

#13 Suggests alternative understanding notpreviously recognized by patient

‘Well, I mean, I think it also speaks to that natural progressioninto adolescence. Sort of checking to see where the boundariesare and pushing the limits and establishing your own senseof boundaries. And I hear that you feel really badly about howyou might have treated her, but I guess where I’m at right nowis wondering how much of that was sort of normal adolescence’;‘The how is always the question. You know, I was thinking of oneof the responses you gave to the inkblot card. It’s the one where yousaid it was the road through the mountains, and I said it’s kind of ametaphor for you really wanting to get somewhere on this road,but it’s kind of hard to get there.’

#19 Focuses on wishes, fantasies, dreams, and earlymemories

‘I was wondering how you have soothed yourself in the past, atleast when you were able to, but I also wonder about thosequalities you talk about in your mom. You talk about her insuch a positive way. And I’m wondering what qualities those are.Tell me a little bit about her’;‘If you could a imagine a conversation you could have with your friendsor your family about this issue, something to explain to them,how would that go, how would it play out?’

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et al., 2009) as well as reconnecting these individuals throughfantasy, imaginal exposure and early memories with morecompassionate representations of themselves and others(McCullough et al., 2003; Schanche, Stiles, McCullough,Svartberg, & Nielson, 2011; Schanche, 2013). In addition,with Nelson’s (2000) assertion that crying displays a rela-tional message, it may be valuable to consider what attach-ment need is conveyed when patients cry, as well as whatthe therapist communicates in their responsivenessthrough this process. Related, it is important to note thatthe standard response of the therapists in this study topatient crying was patience, acceptance and active support(i.e., acknowledgement, normalization and validation) oftheir experience. As such, this response may have beenrelated to the uniformly high alliances reported by boththose patients who did and did not cry during the feed-back session (mean score over 6 on a seven-point scale).Although we are precluded from discussing any sort of

causal relationship, there was a common sequence in thequalitative examination of the clinical process precedingthese crying segments. First was the presence of an affec-tively charged (i.e., intense) topic or theme (positive ornegative valence). Second, this theme or topic was oftenrelational in nature or had to do with the patients’ senseof self (self-efficacy, self-image, self-esteem etc.). Third,this theme, topic or the affective intensity surrounding itmay or may not have been conscious or explicitly recog-nized by the patient. Fourth, the therapist directed the pa-tient to further attend to, expand on or describe theiraffective experience, consider an alternative perspectiveor engage in guided imagery around this particular topic.Again, this clinical sequence should be viewed withcaution and needs additional investigation. In addition,we would add that while this sequence seemed commonin the clinical process of patients who did cry duringfeedback session, the same sequence was often present inthe clinical process of those patients who did not cryduring these sessions. However, given the complete lackof any extant contemporary model on how and whencrying occurs during psychotherapy, we believe it wasimportant to present these observations so that they mightprovide the basis for future hypotheses to be evaluated inboth applied practice and research settings.In sum, it was found that crying could be reliably coded

from videotapes of psychotherapy sessions. Personalityfunctioning was found to be of particular relevance asborderline personality features, and greater emotionalmodulation problems as well as a severity of childhoodsexual abuse were significantly positively correlated withthe number of crying events. Given our findings and thisunderstanding, further research on crying in psychother-apy may guide clinicians in making interventions thatare more tailored to the individual patient’s needs interms of affective expression and integration. Further, theresults indicated that the interventions most frequently

preceding crying focused on affect, new understandingof old patterns and patient fantasies. This knowledgemay be similarly used to inform therapeutic practice.Empirical information about interventions surroundingcrying would also be helpful in providing new clini-cians with training regarding how to understand cryingand how to intervene most effectively. Importantly, it isextremely helpful to note that although sessions inwhich the patient cried appeared to be more difficultfor him or her, the alliance remained unaffected. Inaddition, these process results come from a sample ofpatients who have demonstrated positive large effectsfor both process and outcome data, includingdepressed patients (Hilsenroth et al., 2003), comorbiddepressed and borderline personality disorder patients(Hilsenroth, DeFife, Blake, & Cromer, 2007) and anxietydisorder patients (Slavin-Mulford, Hilsenroth, Weinberger,& Gold, 2011). The positive results can be used as supportfor the statement that effective therapy often involves anelement of discomfort; therefore, the present finding thatthe therapeutic relationship can sustain the normativenegative experience of crying during a session is extremelyencouraging.Among the limitations of this study is that the number

of patients who cried and the sample of crying eventswere small. This limited the manner in which the datacould be analysed and the strength of the conclusions thatcould be drawn. The sample also consisted of outpatientswith mild to moderate psychopathology, and therefore,the findings cannot be reliably extended to severepsychopathology cases and other therapeutic settings.The therapists in this study were graduate trainees in aClinical Psychology Ph.D. programme representing apredominantly psychodynamic orientation. Althoughthey received ongoing, structured (i.e., manuals) andvideotaped supervision during the treatment of thesepatients, future work should examine the issue of patientscrying during treatment with more experienced therapistsrepresenting varying orientations. Despite these limita-tions, we believe that the findings provide considerableinformation about crying in psychotherapy to an almostentirely absent empirical literature on this issue.The findings from this study have laid the ground-

work for future research on patient crying in psycho-therapy. In the future, we would like to examine thetherapist’s post-crying interventions and the relation-ship with the patient’s experience of these sessionswith treatment outcomes. Further, it would be benefi-cial to investigate the differences in patient functioningduring and following sessions in which they criedversus those in which they did not cry. The ultimategoal would be to determine the adaptiveness ofcrying, particularly as related to individual and situa-tional factors. When is crying beneficial, for whom,and under what circumstances?

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