Journal of Psychotherapy Integration © 2016 American Psychological Association

2017, Vol. 27, No. 1, 23–34 1053-0479/17/$12.00 http://dx.doi.org/10.1037/int0000053

Client Perceptions of Corrective Experiences in Cognitive

Behavioral Therapy and Motivational Interviewing for Generalized
Anxiety Disorder: An Exploratory Pilot Study

Jasmine Khattra, Lynne Angus, Kathrin Moertl

Henny Westra, and Christianne Macaulay Sigmund Freud Private University
York University

Michael Constantino
University of Massachusetts Amherst

The purpose of the present study was to qualitatively investigate clients’ posttherapy
accounts of corrective experiences—a proposed common factor and integrative prin-
ciple of therapeutic change (Castonguay & Hill, 2012)—after completion of either a
brief cognitive behavioral therapy (CBT) or motivational interviewing (MI) integrated
with CBT (MI–CBT) for generalized anxiety disorder (GAD; Westra, Constantino, &
Antony, 2016). Patients’ Perceptions of Corrective Experiences in Individual Therapy
(PPCEIT; Constantino, Angus, Friedlander, Messer, & Heatherington, 2011) semistruc-
tured interviews were completed at therapy termination with 1 MI–CBT client and 1
CBT-only client who met the criteria for recovery. The PPCEIT interviews were
audiorecorded, transcribed, and subjected to a grounded theory analysis using qualita-
tive research methods software (ATLAS.ti). Findings indicated that both clients re-
ported positive shifts in their experience of anxiety and increased agency in interper-
sonal relationships. In particular, the client undergoing integrative MI–CBT treatment
reported increased confidence in her own ability to maintain positive changes post-
therapy, while the CBT-only client expressed confidence in her application of CBT
tools and skills to maintain therapy outcomes. The MI–CBT client attributed the shifts
she experienced in therapy to an increased awareness and confidence in her own
agency, indicating a potential corrective experience of self, whereas the CBT-only
client attributed the positive shifts she experienced to the expertise provided by the
therapist. Future research directions are discussed, in addition to implications of
integrative CBT approaches, for enhanced clinical outcomes.

Keywords: corrective experience, cognitive behavioral therapy, motivational interview-

ing, generalized anxiety disorder, shifts in therapy

Alexander and French (1946) introduced the transference-focused, psychodynamic therapy

therapeutic principle of corrective emotional sessions. Specifically, they posited that when
experience to describe how patients repair mal- psychodynamic therapists provide an opportu-
adaptive interpersonal patterns in the context of nity to reexperience and understand early emo-
tional conflicts in the context of a safe, respon-
sive therapeutic relationship, clients begin to
This article was published Online First August 8, 2016. challenge and revise negative beliefs and expec-
Jasmine Khattra, Lynne Angus, Henny Westra, and Chris- tations about themselves and others. The defi-
tianne Macaulay, Department of Psychology, York University;
Kathrin Moertl, Department of Psychology, Sigmund Freud
nition and nature of corrective emotional expe-
Private University; Michael Constantino, Department of Psy- riences has been extensively debated and
chology, University of Massachusetts Amherst. theorized (Palvarini, 2010) since Alexander and
Correspondence concerning this article should be ad- French’s original publication in 1946. A shared
dressed to Jasmine Khattra, Department of Psychology,
York University, Graduate Psychology Office 297, Behav-
consensus on what is corrective, what gets cor-
ioural Science Building (BSB), 4700 Keele Street, Toronto, rected, and the mechanisms that underlie mean-
ON M3J 1P3. E-mail: [email protected] ingful corrective shifts for clients in psychother-
23
24 KHATTRA ET AL.

apy has nonetheless eluded psychotherapy Investigating Client CEs in CBT

researchers and practitioners, perhaps because
the construct has traditionally been framed in Heatherington, Constantino, Friedlander, An-
psychodynamic terms, limiting the scope of re- gus, and Messer (2012) conducted a multisite
search inquiry into the nature of corrective ex- study to investigate clients’ (N 76) first-
periences (CEs) in therapy. person accounts of CEs immediately after every
In a recent effort to address this gap in the fourth therapy session. Clients were asked to
psychotherapy research and practice literature, describe what changed (“Have there been any
Castonguay and Hill (2012) proposed a pan- times since you started the present therapy that
theoretical, integrative definition of CEs in psy- you have become aware of an important or
chotherapy: “ones in which a person comes to meaningful change[s] in your thinking, feeling,
understand or experience affectively an event or behavior, or relationships?”) and how they
a relationship in a different or unexpected way” thought the change had occurred (“If yes, what
(p. 5). do you believe took place during or between
Throughout the remainder of this paper, we your therapy sessions that led to such chang-
use the term corrective experience to indicate e[s]?”). For clients engaged in CBT, five key
this broader, pantheoretical definition proposed themes emerged from the qualitative analysis of
by Castonguay and Hill (2012). The purpose of postsession accounts addressing what changed
arriving at this broader definition was to invite in therapy sessions: acquisition and use of new
future psychotherapy research studies address- skills, recognition of hope, a more positive
sense of self, specific changes in behavior (such
ing client CEs from differing theoretical orien-
as reduction in psychological symptoms or a
tations and psychotherapy models (Castonguay
shift in interpersonal patterns), and new cogni-
& Hill, 2012). CEs differ from positive out-
tive perspectives on life and interpersonal rela-
comes of therapy in that CEs are novel, person-
tionships. In terms of perceptions of how
ally significant, surprising, disconfirming of
change happens, the most commonly cited CBT
past experiences, and/or can have a significant therapist interventions were providing a new
impact on the clients’ understanding of the self, understanding of the client’s problems; giving
the world, and intra- and interpersonal patterns, advice; teaching specific techniques; and ob-
along with concrete shifts in their thoughts, serving client patterns of thoughts, feelings, and
feelings, and behaviors. There may be overlap behaviors. Themes pertaining to clients’ contri-
in clients’ accounts of positive outcomes of butions to the change process included greater
therapy and CEs, given that both can be emo- awareness and self-reflection, implementing
tional, cognitive, behavioral, or relational in na- specific techniques learned in therapy to daily
ture. However, further research on clients’ per- life, and cooperating with the therapist (Heath-
spectives of CEs can clarify the current erington et al., 2012). While these findings pro-
conceptualization of CEs, which to date in- vided an interesting window into clients’ per-
cludes mostly psychotherapists’—rather than ceptions of postsession change in CBT, the
clients’— understanding of CEs. analyses were limited by the brevity of postses-
Building on this integrative research initia- sion written accounts and the absence of infor-
tive, the primary goal of the present exploratory mation regarding client pretreatment diagnosis
study was to investigate the presence and nature and outcome status at treatment termination and
of CEs in two clients’ firsthand accounts of their follow-up.
experience of cognitive behavioral therapy In order to help address these methodological
(CBT) and CBT integrated with motivational gaps in future studies, Constantino, Angus,
interviewing (MI) for generalized anxiety dis- Friedlander, Messer, and Heatherington (2011)
order (GAD; Westra, Constantino, & Antony, codeveloped a posttreatment interview protocol
2016). Specifically, the present study aimed to called Patients’ Perceptions of Corrective Expe-
identify preliminary evidence for the validity of riences in Individual Therapy (PPCEIT). The
the updated, integrative, pantheoretical defini- PPCEIT interview protocol is a semistructured
tion of CE and potential themes to inform a interview containing 10 open-ended questions
future larger study on CEs in the same clinical divided into four sections. The sections ask cli-
sample. ents to identify and elaborate on (a) the primary
 CLIENT CORRECTIVE EXPERIENCES 25

reasons that they sought out therapy; (b) what Morrison, 2001). As such, many questions still
significant shifts the client experienced in his or remain as to the specific relational or treatment
her view of self, life, interpersonal relation- factors in brief CBT treatment protocols that
ships, and problematic patterns; (c) the client’s contribute to clients’ sustained recovery from
attributions for meaningful shifts in therapy, GAD. For example, it may be the case that
focusing on specific significant or unexpected recovered clients experience shifts in their un-
incidents or therapist interactions; and (d) any derstanding of the self or in relation to the
other meaningful experiences in therapy and therapist (i.e., a CE) above and beyond learning
their overall experience of participating in the and applying CBT skills for managing worry
interview. and anxiety. The randomized controlled trial
While previous posttherapy interview proto- (RCT) from which the present study’s partici-
cols have investigated clients’ retrospective per- pants were drawn included clients who received
ceptions of psychotherapy (change interview: CBT alone and clients who received MI inte-
Elliott, Slatick, & Urman, 2001; narrative as- grated with CBT (Westra et al., 2016). Impor-
sessment interview: Hardtke & Angus, 2004; tantly, MI emphasizes the importance of the
Kertes, Westra, Angus, & Marcus, 2011), the therapeutic relationship, empathic exploration
PPCEIT interview protocol (Constantino et al., of client values and identity, and heightening
2011) is unique in that it addresses not only client collaboration and agency in the change
what clients perceive to be corrective about process (Westra, 2012). As such, this study
their experiences in psychotherapy but also in- sample thus represents an opportunity to eluci-
quires about their own personal understanding date key distinctions between the types of
of how those changes occurred. Specifically, changes clients experienced in therapy, such as
questions posed in the what shifted domain pro- distinctions between symptom level and gaining
vide clients with an opportunity to identity expertise in CBT skills changes, versus higher
meaningful shifts in multiple areas of their lives, order shifts in experience or understanding of
such as their view of self, outlook on life, inter- the self, events, or relationships (i.e., CEs).
personal relationships, thoughts, feelings, behav-
iors, and problematic patterns. Similarly, ques- The Current Study
tions in the how shifts occur domain probe for
specific moments within therapy and the thera- The present study conducted a qualitative
peutic relationship that lead to shifts, which is analysis of client accounts of meaningful shifts
unique to the PPCEIT interview protocol. This experienced in the context of an RCT of CBT
additional element appears to contribute impor- versus Motivational Interviewing integrated
tant information to our understanding of CEs. with CBT (MI–CBT) for GAD (Westra et al.,
For example, Friedlander and colleagues (2012) 2016) using the PPCEIT interview protocol
administered the PPCEIT interview protocol to (Constantino et al., 2011). Qualitative analyses
investigate client CEs in one good-outcome cli- of the protocol were guided by the following
ent engaged in short-term dynamic psychother- exploratory research questions: (a) What core
apy. In terms of therapeutic change, the client themes emerge from clients’ verbal accounts of
identified resolution of unfinished business perceived meaningful and significant shifts in
from childhood and more adaptive interpersonal CBT and MI–CBT for GAD? and (b) What core
relationships as CEs at therapy termination and themes emerge from clients’ verbal accounts of
attributed these shifts to the motivation, safety, how those shifts occurred?
and acceptance provided by her psychodynamic In order to investigate client accounts of
therapist. meaningful shifts in CBT and MI–CBT, the
To date, no studies have investigated client PPCEIT interview protocol (Constantino et al.,
posttherapy accounts of CEs in mainstream 2011) was administered to one recovered CBT
therapy approaches such as CBT for depression client and one recovered MI–CBT client who
or GAD. While research evidence generally completed the semistructured interview proto-
supports the efficacy of CBT for GAD (see col at treatment termination. The interviews
Covin, Ouimet, Seeds, & Dozois, 2008), a sub- were audiorecorded, transcribed, and subjected
stantial number of clients fail to fully recover by to a grounded theory analysis using qualitative
treatment termination and follow-up (Westen & research methods software, ATLAS.ti (Muhr,
26 KHATTRA ET AL.

1997), to generate themes. Selecting a client over the follow-up period and either no change
from each treatment condition for this pilot or a slight worsening over time for the CBT-
study allowed an initial comparison of the im- alone group (Westra et al., 2016). See Table 1
pact of treatment differences that emerged in the for clients’ pretreatment, posttreatment, and 12-
results to be explored in future larger samples. month follow-up PSWQ scores.
The pseudonym “Deb” was given to the cli-
Method ent who completed CBT-only treatment and the
pseudonym “Martha” was given to the client
Participants who completed MI–CBT treatment to preserve
confidentiality and anonymity. Deb was a 28-
Selection pool. Client posttreatment ac- year-old Caucasian female with a postsecond-
counts were solicited in the context of a larger ary degree who had a comorbid diagnosis of
RCT (Westra et al., 2016) of CBT versus CBT major depression, panic disorder, and social
integrated with MI for GAD. Participants had a phobia at baseline. Martha was a 53-year-old
principal diagnosis of GAD as assessed by a Caucasian female with a master’s degree who
modified Structured Clinical Interview for had no other comorbid conditions at baseline.
DSM–IV–TR Axis I Disorders (SCID–IP; First, Both Deb and Martha had had previous experi-
Spitzer, Gibbon, & Williams, 2002) and a score ence with psychotherapy treatment (Deb: 17
above the cutoff for high-severity GAD on the CBT sessions with a psychologist; Martha: 10
Penn State Worry Questionnaire (PSWQ; therapy sessions with a social worker).
Meyer, Miller, Metzger, & Borkovec, 1990).
Participants (N 85) were randomly assigned Therapists
to either receive 15 weekly sessions of CBT or
four individual MI sessions prior to receiving 11 Deb’s therapist was a 28-year-old Caucasian
weekly CBT sessions (MI–CBT), integrated female who was a master’s-level trainee in su-
with MI as needed. A total of 19 posttherapy pervised practicum training. Martha’s therapist
interviews were randomly conducted by two of was a 32-year-old Caucasian female who had
the authors who were trained in the administra- recently completed her PhD. Therapists in the
tion of the PPCEIT interview protocol (Con- RCT self-selected the training and delivery of
stantino et al., 2011). The two clients included the treatment condition to enhance their fidelity
in the current study were selected because they to the MI–CBT or CBT treatment protocols.
were the first pair (i.e., one from each treatment Training consisted of readings, 4-day-long
condition) of interviewees who met the recov- workshops including discussion and role-play,
ered status at treatment termination and had and at least one practice case with intensive
thorough interviews. feedback and video review of therapy sessions.
Reliable change index (Jacobson & Truax, Treatment
1991) analyses of the PSWQ (Meyer et al.,
1990) scores at posttreatment were conducted to The CBT-only client (Deb) received 15
determine the outcome status categorization of weekly sessions of CBT, which included the
the CBT-only and MI–CBT client for inclusion following components: psychoeducation for
in the current study. Both clients were consid-
ered recovered at treatment termination. How-
ever, the CBT client relapsed, while the MI–
CBT client was still considered recovered at 12 Table 1
Client PSWQ Scores at Pretreatment,
months follow-up. It should be noted that the
Posttreatment, and 12 Months Follow-Up
12-month follow-up scores were made available
to the authors after the qualitative analyses of 12 months
the current study had already been completed. Client Pretreatment Posttreatment follow-up
The trend in PSWQ scores of the two clients is Deb (CBT) 80 51 75
consistent with the overall RCT results that Martha (MI–CBT) 68 32 20
show a consistent, significant pattern across Note. PSWQ Penn State Worry Questionnaire; CBT
self-report and diagnostic measures, indicating cognitive behavioral therapy; MI–CBT Motivational In-
increasing improvement for the MI–CBT group terviewing integrated with CBT.
 CLIENT CORRECTIVE EXPERIENCES 27

anxiety and worry, self-monitoring, progressive sought out therapy. The second and third sec-
muscle relaxation training, discrimination train- tions invite clients to share their experiences of
ing, cognitive restructuring, behavioral experi- what shifted in therapy and how these meaning-
ments, imagined and in vivo exposure to worry ful shifts came about, respectively. The fourth
cues, prevention of worry-related behaviors, and final section of the PPCEIT interview pro-
discussion of sleep strategies, and relapse pre- tocol inquires about any other meaningful ex-
vention planning. periences in therapy and the client’s experience
The MI–CBT client (Martha) received four of participating in the interview.
sessions of MI followed by 11 sessions of CBT,
integrated with MI techniques when markers of Procedure
ambivalence and resistance emerged. The MI
treatment consisted of principles and methods Data analysis. Interviews were audiore-
outlined by Miller and Rollnick (2002), target- corded, transcribed, and analyzed using ATLAS.ti
ing ambivalence about worry and worry-related (Muhr, 1997) scientific software that is de-
behaviors. Core strategies and principles of MI signed to implement a grounded theory analysis
(expressing empathy, rolling with resistance, (Angus & Rennie, 1988, 1989; Glaser &
developing discrepancy, and enhancing self- Strauss, 1967).
efficacy) are differentiated from the underlying Grounded theory. The grounded theory
MI spirit. The MI spirit is a client-centered approach is a “qualitative research method that
relational stance involving empathic attun- uses a systematic set of procedures to develop
ement, collaboration, evocation, and respect for an inductively derived grounded theory about a
the client’s autonomy (Angus, Watson, Elliott, phenomenon” (Strauss & Corbin, 1990, p. 24).
Schneider, & Timulak, 2015). CBT therapists Glaser and Strauss (1967) originally developed
actively take on the role of change advocate, this approach as an alternative to deductive the-
whereas MI therapists facilitate the client to orizing methods in which data are forced to fit
explore their own thoughts and feelings about into existing theories. The grounded theory
change, helping the client become a more effec- method used in the current study is based on an
tive advocate for his or her own change. Al- integration of grounded theory methods out-
though MI has several directive components lined by Angus and Rennie (1988, 1989) and
aimed at increasing client self-change talk, the Glaser and Strauss (1967).
focus remains on increasing motivation for The interview transcripts were first divided
change instead of primarily employing change into meaning units, which are text segments
strategies. (usually a few lines to a paragraph) that convey
a single topic or focus. The next step involves
Measures identifying properties in each meaning unit. The
term properties refers to individual and new
PSWQ (Meyer et al., 1990). The PSWQ is ideas conveyed by the client within a larger
a widely used measure in assessing trait worry. meaning unit. Property titles were kept descrip-
The 16 items on the PSWQ are rated on a tive and close to the client’s language. As the
5-point Likert scale, with higher scores indicat- analysis progressed, new meaning units were
ing higher levels of worry. The PSWQ has been compared to existing properties. If no existing
found to hold high internal consistency, have properties were representative of an individual
good test–retest reliability, and have good con- idea within a meaning unit, a new property was
vergent and discriminant validity (Brown, developed. Properties were further clustered
Antony, & Barlow, 1992). into categories, the titles of which shifted from
PPCEIT (Constantino et al., 2011). being entirely descriptive when identifying
Clients were interviewed at therapy termination properties to conceptual, abstract themes when
using the PPCEIT interview protocol, which labeling categories in order to explain the prop-
contains 10 open-ended questions that are di- erties’ descriptive content. Categories with re-
vided into four sections. The interview protocol lationships to multiple other categories were
is outlined in an interview manual (Constantino, termed central or core categories (Angus &
Angus, & Moertl, 2012). The first section asks Rennie, 1988, 1989). The linked categories
clients to identify the primary reasons they were then organized into a hierarchical structure
28 KHATTRA ET AL.

in which core categories subsumed lower order Table 3

categories, defining the core category proper- Taxonomy of Properties for the Domain of Clients
ties. In the present study, the transcripts were Accounting How Shifts Occurred in Therapy
coded into meaning units and properties and Category
clustered into categories by a single coder. A
Core Category 4: Therapist’s positive role in facilitating
senior researcher and clinical psychologist ver- shifts in therapy
ified the meaning units and properties against (a) Therapist as an expert and guide in therapy
the raw language used by the client and audited (a1) Therapist provides helpful information and
the properties as well as their categorization into resources
lower order categories and core categories. (a2) Therapist helped facilitate new perspectives on
anxious thoughts and self-reflection for the client
(b) Positive therapeutic relationship enhanced therapy
Results experience
Core Category 5: New intrapersonal and interpersonal
Tables 2 and 3 present the core themes and awareness derived from therapy
subcategories that emerged from the qualitative (a) Insight into previously unacknowledged thoughts
analysis of Deb and Martha’s posttreatment ac- and emotions in therapy
counts of their therapy experiences. The emer- (b) Self-realization to give priority to one’s own needs
before others: Shift from other focused to self
gent core themes were grouped in terms of two focused
domains—(a) client-identified shifts in therapy Core Category 6: Learning helpful CBT exercises and
and (b) clients accounting how shifts occurred tools to manage anxiety on an everyday basis
in therapy—to address Research Questions a (a) Muscle relaxation exercises useful in recognizing
and b, respectively. bodily tension
(b) Thought records helpful due to their practical value
Domain 1: Client-Identified Shifts in in organizing anxious thoughts in stressful
situations
Therapy
Note. CBT cognitive behavioral therapy.
Core Category 1: More adaptive interper-
sonal relationships due to therapy. This
core category includes Deb and Martha’s de-
scriptions of experiencing maladaptive interper-
sonal patterns with a new outcome within the
Table 2
therapeutic relationship as well as examples of
Taxonomy of Categories for the Domain of Client-
improved interpersonal relationships outside the
Identified Shifts in Therapy
context of therapy.
Category (a) Experiencing old interpersonal patterns
Core Category 1: More adaptive interpersonal with a new outcome in the therapeutic
relationships due to therapy relationship. Martha reported replaying her
(a) Experiencing old interpersonal patterns with a new maladaptive interpersonal pattern of wanting to
outcome in the therapeutic relationship be perceived perfectly in the therapeutic rela-
(b) Increased independence in interpersonal tionship:
relationships
Core Category 2: Positive shifts in the experience of I slowly started to realize that I like to be perfect, I like
anxiety to be friendly. So I was trying to be the perfect client,
(a) New awareness about the nature of anxiety: From what if she (therapist) thinks I am crappy at this or that
feeling stuck in a box to expanded perspectives I am terrible?
(b) Change in anxiety-related behaviors that are
observable in everyday life: Feeling more calm and After a discussion with her therapist, Martha
present centered reported that she came to understand this inter-
Core Category 3: Feeling a sense of hopefulness about personal pattern in a new way and apply this
changes accomplished in therapy
(a) Feeling confident in sustaining progress
awareness within the therapeutic relationship
accomplished in therapy through reliance on inner and to relationships outside the therapeutic con-
self-efficacy text:
(b) Feeling confident in sustaining progress
accomplished in therapy by learning and applying I was trying to be perfect. I was trying to measure up
CBT tools to what I thought everyone else thought I should be.
Now, it’s okay to be who I am and do what I am doing
Note. CBT cognitive behavioral therapy. . . . I am not so concerned about if they . . . are thinking
 CLIENT CORRECTIVE EXPERIENCES 29

critically about me. . . . At Christmastime, I wanted to • “Before starting therapy, my worry was
bake some cookies and bring them to her [therapist]. like a train, so it was thought after thought
But I didn’t because I didn’t think it was totally nec-
essary, which is a good thing. after thought. But now, it is easier for me to
break that up” (Deb).
Deb also reported becoming more aware of • “The more we talked about what was that
her interpersonal pattern of “worrying about the thought? Why did you think that way? I
therapist being upset about something” and started seeing, oh okay, I can stop, look at it,
“apologizing too much” after the therapist slow it down, and try to reframe it” (Martha).
pointed it out to her. After discussing this inter- Although Deb reported realizing that she
personal pattern with the therapist, Deb noted would “always have anxiety,” she noted being
the following: “There are situations now where able to view her anxious thoughts in a more
I will be doing something, I think to myself, do objective manner now, similar to Martha, who
I need to apologize for that? I try and like, go also noted being able to view her anxiety from
back to therapy.” “another person’s point of view.”
(b) Increased independence in interpersonal (b) Change in anxiety-related behaviors that
relationships. This subcategory contains cli- are observable in everyday life: Feeling more
ents’ responses in which they reported experi- calm and present centered. Only Martha re-
encing more adaptive interpersonal relation- ported instances of taking action and changes in
ships characterized by an enhanced sense of anxiety-related behaviors while noting a signif-
agency and independence. For example: icant reduction in her anxiety. She noted:
• “I am trying to get myself a little less
I didn’t like open time where there was nothing
dependent. So I think my husband is hap- planned. I would get restless and feel like I should be
pier and together we are a little bit better” productive. But now I am okay with downtime, like to
(Deb). spend a Sunday in my sweats, stay at home and watch
• “I have always been very overprotective of movies, I never did that before. It feels good because I
my brother. But I am trying to . . . let him feel calmer. I am definitely less tired than I was.
deal with his own issues. I would never She also noted: “My mind isn’t racing as
have thought of doing that before” (Deb). much. And I am sleeping better. I wake up in
• “My mom has Alzheimer’s and my dad is the morning and go, hmm, I don’t feel tired. So
taking care of her. . . . He was angry and I that’s nice! It’s a surprise.”
got the brunt of it. . . . I would worry about Core Category 3: Feeling a sense of hope-
my dad. . . . What should I be doing? Now, fulness about changes accomplished in
I am doing what I can and I am not . . . therapy. This core category includes clients’
looking for more to compensate” (Martha). descriptions of deriving confidence from
Core Category 2: Positive shifts in the ex- changes accomplished in therapy and growing
perience of anxiety. This core category in- optimism about the future.
cludes Deb and Martha’s reports of positive (a) Feeling confident in sustaining progress
shifts in how they view and experience anxiety, accomplished in therapy through reliance on
which they attributed to their engagement in inner self-efficacy. This subcategory reflects
CBT and MI–CBT, respectively. Martha’s responses; she reported increased confi-
(a) New awareness about the nature of anx- dence about the positive shifts she accomplished
iety: From feeling stuck in a box to expanded in therapy as well as taking responsibility in terms
perspectives. Deb described a transition in of creating and sustaining these shifts: “In the
viewing her anxiety from “being stuck in a box” questionnaire that we fill out every session, that
with a limited perspective to deriving a new question of what percentage of your symptoms do
perspective about the nature of anxiety by you feel have improved, I would always say, 60%
equating it to “bringing a new light” to it. Both and then later on, I thought, maybe 80%.” She
clients described a meaningful shift such that also noted: “I was never skeptical that the therapy
instead of viewing their worry as unmanageable process was effective, it was more, could I do it?
and overwhelming, they came to see it as some- So more about myself than therapy itself.” Al-
thing they could learn to work with. For exam- though Martha described realistic concerns about
ple: keeping up with therapy progress, her responses
30 KHATTRA ET AL.

also indicated hopefulness and a belief in her own The therapist asking me a lot of questions made me really
ability to continue moving forward: think and gave me a chance to look at things from a
different perspective. . . . She would come back with a
I am a bit nervous because I have been dealing with it question, which I would be like, whoa!, she stumped me.
for 30 years. If I introduce more stress back, would I be And I’d think wow, I never thought of it like that!
able to keep it up? But I am thinking more and more
that I can. I can think differently. (b) Positive therapeutic relationship en-
hanced therapy experience. Both clients de-
(b) Feeling confident in sustaining progress
scribed the positive therapeutic relationship as
accomplished in therapy by learning and ap-
plying CBT tools. This subcategory contains providing them with a safe space to open up.
Deb’s responses; she described feeling equipped During a particularly stressful week, Deb noted:
with various tools learned from therapy for appli- “She said, today we are not going to have a
cation to outside situations: “At least I have all this schedule, I want you to talk about what you feel
information and tools that I can use when every- like you need to talk about. So she let me vent.
thing in my life returns to normal.” She also noted: I really needed it.” Martha noted: “That was a
“Once life gets a little bit more back to normal, I surprise that I didn’t expect to cry as much as I
can still do all this stuff that I have been doing in did.” In addition, Deb reported that the therapist
therapy.” She also noted deriving confidence from possessed a “very warm demeanor and person-
applying CBT tools and observing the positive ality,” which helped increase her trust in the
results: “Doing thought records, relaxation exer- therapy process and relationship:
cises, I have come into this brand-new profession
It felt like she truly cared. She wasn’t just saying
with no experience and I am still there and they whatever because it’s part of her job, it felt like a real
haven’t fired me yet. So this is a good sign.” sense of her personality came through, which is im-
portant because I didn’t want to talk to a robot.
Domain 2: Clients Accounting How Shifts
Occurred in Therapy Core Category 5: New intrapersonal and
interpersonal awareness derived from
Core Category 4: Therapist’s positive role therapy. The majority of the properties in this
in facilitating shifts in therapy. This core core category represent Martha’s responses in
category includes Deb and Martha’s descrip- which she described how gaining awareness of
tions of the positive role played by the therapist her underlying beliefs and interpersonal patterns
in facilitating shifts.
helped her accomplish meaningful shifts in ther-
(a) Therapist as an expert and guide in
apy.
therapy. The majority of the properties in this
subcategory represented Deb’s responses, (a) Insight into previously unacknowledged
which reflected the therapist actively guiding thoughts and emotions in therapy. The prop-
the therapy process and providing expertise. erties in this subcategory emerged from Mar-
(a1) Therapist provides helpful information tha’s account in which she spoke about realizing
and resources. All the properties in this sub- the extent to which she was “criticizing herself
category came from Deb’s responses in which on the inside” and trying to “measure up to an
she spoke about the therapist supplying her with unrealistic standard.” She noted:
resourceful information that provided her with I always thought I should be able to do more, more,
clarity when “everything seemed cloudy.” Her and more. It was never enough. Because of this, in the
responses reflected the therapist being a knowl- last 5 years, I realized that no matter what I did, I was
edgeable guide who helped her overcome diffi- exhausted. So mentally, I was burnt out.
culties with therapy exercises: “Everything that
she was asking me to do or ideas that she had, She noted a specific incident in therapy when
I agreed with everything she was suggesting experiencing emotions acted as a cue to her un-
because I felt like it was helpful.” derlying fears:
(a2) Therapist helped facilitate new perspec-
It was around the fourth session when the therapist
tives on anxious thoughts and self-reflection for started to get to me and I felt emotional. . . . It started
the client. Martha spoke about the therapist with her asking me questions and then I felt like
“opening her mind” to new perspectives on her crying. . . . And then I started to realize some of my
anxiety. Similarly, Deb noted: fears and how much they were part of me, like people
 CLIENT CORRECTIVE EXPERIENCES 31

not liking me, getting old, and fat. I realized how much Castonguay & Hill, 2012). Two recovered cli-
they mean to me. ents were solicited from an RCT of CBT versus
(b) Self-realization to give priority to one’s MI–CBT (Westra et al., 2016) and interviewed
own needs before others: Shift from other fo- at posttreatment using the PPCEIT interview
cused to self focused. Both clients came to the protocol (Constantino et al., 2011). The small
realization that they were investing more into sample size limits generalization, and system-
their interpersonal relationships instead of fo- atic differences in age, education level, and
cusing on their own needs and priorities. For comorbid diagnoses at baseline between the
example, Deb stated: “I realized I was paying CBT and MI–CBT clients, as well as therapist
way too much attention to everyone else and not differences, may have partially accounted for
doing enough for myself. . . . I am realizing to the findings. However, our findings are promis-
step back and disconnect a little bit to keep ing in terms of implications for future research
myself sane.” Martha noted: with a larger sample and for clinical practice.
The emergent core themes and subcategories
I would go for a massage and then chat through the in the domain of client-identified shifts in ther-
whole thing about their life and then I come to the end
of the thing and go, that was not the point. . . . I notice apy indicated that Martha and Deb reported
now when other people do not ask about me. So it’s a several meaningful shifts in their therapy pro-
one-sided relationship. . . . So I realized, being nice and cess, a few of which were congruent with the
polite is good but not to go too far. following pantheoretical, transdiagnostic defini-
Core Category 6: Learning helpful CBT ex- tion of CEs: “ones in which a person comes to
ercises and tools to manage anxiety on an ev- understand or experience affectively an event or
eryday basis. This core category emerged from a relationship in a different or unexpected way”
Deb’s description of helpful CBT exercises and (Castonguay & Hill, 2012, p. 5).
tools that she learned from therapy. Specifically, the two subcategories in the core
(a) Muscle relaxation exercises useful in rec- theme of more adaptive interpersonal relation-
ognizing bodily tension. Deb spoke about the ships due to therapy are consistent with the
helpful aspects of learning progressive muscle conceptualization of CEs (Castonguay & Hill,
relaxation in therapy and incorporating it into 2012). The subcategory of experiencing old in-
her daily life. She mentioned now being able to terpersonal patterns with a new outcome in the
identify tension in her body and being able to therapeutic relationship highlighted that both
use it as a “sign to relax.” clients identified a meaningful interpersonal
(b) Thought records helpful due to their prac- shift or CE within the therapeutic relationship,
tical value in organizing anxious thoughts in which is in agreement with the transtheoretical
stressful situations. Deb noted that the thought definition (Castonguay & Hill, 2012) and orig-
records were her “favorite part” of therapy in inal conceptualization of CEs (Alexander &
terms of their value in helping her “break down French, 1946). Both clients came to replay as
and analyze” her worries in everyday situations. well as understand and experience their old
She also spoke about utilizing the thought re- maladaptive interpersonal pattern with a new
cords during and after therapy, which helped solution within the context of the therapeutic
her “recognize the underlying cause of negative relationship. In both instances, instead of reaf-
thoughts.” firming their interpersonal pattern as others had
done before, the therapist facilitated a new cor-
Discussion rective interpersonal experience through an
open discussion within the context of warmth,
This pilot study utilized a grounded theory genuineness, and safety of the therapeutic
analysis to identify core themes in clients’ post- space. The subcategory of increased indepen-
therapy accounts of shifts experienced in CBT dence in interpersonal relationships included
or MI–CBT for GAD. Our goal was to identify Deb and Martha’s examples of specific shifts in
core themes about what shifted and how it the way they experienced interpersonal relation-
shifted and to identify whether any of those ships with significant others outside the context
shifts might constitute a CE (i.e., a new under- of the therapeutic relationship due to therapy,
standing or unexpected, novel emotional expe- which is also consistent with Castonguay and
rience of an event, the self, or a relationship; Hill’s (2012) conceptualization of CEs.
32 KHATTRA ET AL.

The core theme of positive shifts in the ex- tion for change reside within the client (Miller
perience of anxiety highlighted that both clients & Rollnick, 2002).
indicated cognitive and experiential shifts in The aforementioned findings are also consis-
relation to their anxiety and worry. Although tent with the theoretical rationale for integrating
these responses were evoked in response to MI with more directive therapeutic approaches
questions that pull for significant and personally such as CBT to increase clients’ active engage-
meaningful shifts within therapy in the PPCEIT ment and motivation for change in treatment
interview protocol (Constantino et al., 2011), (Miller & Rollnick, 2002). Specifically, CBT
these shifts do not meet the definition of CEs requires that the client engage in several tasks
(Castonguay & Hill, 2012). and exercises with a clear orientation toward
In the core theme of feeling a sense of hope- changing one’s thinking and behaviors, which
fulness about changes accomplished in therapy, can be a potent breeding ground for resistance
both clients noted a shift from feeling hopeless (Westra, 2012). MI is then added to mobilize
about the future to enhanced optimism in main- the client’s intrinsic motivation for movement
taining changes accomplished in therapy. While toward change, which is thought to inherently
this core theme is representative of a positive increase engagement in treatment. Increased
outcome of the clients’ therapeutic experiences, treatment engagement as a function of receiving
the subcategories within the theme do not com- MI was observable in Martha’s accounts of how
ply with the pantheoretical definition of CEs shifts occurred; she attributed them to the
(Castonguay & Hill, 2012). What is notable awareness and insights derived by her agentic
here is that while there were many commonal- self, whereas Deb attributed her CEs to the
ities in Deb and Martha’s accounts of increased therapist’s guidance and CBT tools, which is
hopefulness, differences were apparent in their congruent with the didactic nature of CBT.
perceptions of what their roles were in main- In addition to enhanced engagement in treat-
ment, Martha’s (MI–CBT) PSWQ scores indi-
taining shifts from therapy. Martha expressed
cated an enhanced treatment outcome compared
confidence about maintaining changes through
to Deb (CBT only) at 12 months follow-up—
a belief in her own inner resources, whereas
that is, although both clients were considered to
Deb expressed similar optimism but through the
have recovered from GAD at posttreatment,
application of CBT tools learned from therapy.
Martha retained her treatment status of recov-
This difference was also paralleled in their de- ered at 12 months follow-up, while Deb re-
scriptions of how they perceived CEs to have lapsed at 12 months follow-up. If these two
occurred. The bulk of Deb’s responses fell un- cases are representative of the treatment condi-
der the core themes of therapist’s positive role tions from which they were sampled, then these
in facilitating shifts in therapy and learning findings indicate that MI integrated with CBT
helpful CBT exercises and tools to manage anx- might improve treatment outcomes through the
iety on an everyday basis. Salient in Deb’s pathway of the MI spirit and client-as-expert
responses was a sense that she experienced the nature, which engenders clients with an agency
therapist as the expert and guide who acted as and trust in themselves, as observed in Martha’s
the primary manager of the therapy sessions posttreatment. In contrast, Deb’s account sug-
(e.g., agreeing with the therapist’s suggestions, gested her dependence on therapist guidance.
complying with homework and exercises). Deb This distinction might be particularly relevant
also attributed her shifts in therapy to thought once treatment ends and clients have to rely on
records and muscle relaxation. themselves. In addition to capturing the nature
In contrast, Martha’s descriptions of attribu- and attributions of meaningful shifts from the
tions for shifts mainly fell under the core theme clients’ perspectives, the results of the present
of new intrapersonal and interpersonal aware- study also provide preliminary evidence that
ness derived from therapy. In Martha’s accounts CEs are experienced by clients undergoing MI
of how CEs occurred, she noted working hard at and CBT for GAD. Finally, our findings tenta-
gaining a deeper understanding of herself and tively suggest that the theoretically intended
finding her own answers. This difference may mechanisms of change in MI and CBT are con-
reflect key elements of the MI spirit, which sistent with clients’ subsequent accounts of
emphasizes the view that resources and motiva- shifts experienced in therapy, and these may
 CLIENT CORRECTIVE EXPERIENCES 33

point to pathways through which MI may exert metaphoric expression in psychotherapy. Psycho-
better long-term benefits than CBT alone. therapy: Theory, Research, Practice, Training, 26,
372–379. http://dx.doi.org/10.1037/h0085448
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An important limitation of this pilot study tion to evidence-supported treatment outcomes and
was the small sample size. It should also be beyond. Psychotherapy Research, 25, 330 –347.
noted that differences in age, education, comor- http://dx.doi.org/10.1080/10503307.2014.989290
bid diagnoses at baseline, and therapist differ- Brown, T. A., Antony, M. M., & Barlow, D. H. (1992).
ences between the CBT-only client and MI– Psychometric properties of the Penn State Worry
CBT client could have contributed to systematic Questionnaire in a clinical anxiety disorders sample.
differences in long-term outcome as well as the Behaviour Research and Therapy, 30, 33–37. http://
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In future studies, it will be important to ex-
periences across cognitive behavioral, humanistic,
plore if key differences in agency and self- and psychodynamic approaches. Washington, DC:
efficacy, as noted in the MI–CBT client’s de- American Psychological Association. http://dx.doi
scriptions of meaningful shifts, also arise in a .org/10.1037/13747-000
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MI–CBT for GAD, which may add to the grow- Messer, S. B., & Heatherington, L. (2011). Pa-
ing understanding of how MI may increase re- tients’ perceptions of corrective experiences in in-
ceptivity to more action-oriented treatments dividual therapy interview protocol. Unpublished
such as CBT. It would also be informative to interview protocol, University of Massachusetts at
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