What Clients Find Helpful in Psychotherapy: Developing Principles forFacilitating Moment-to-Moment ChangeHeidi Levitt, Mike Butler, and Travis HillUniversity of MemphisClients who had completed psychotherapy were interviewed about the significant experiences andmoments they recalled within their sessions. These interviews were analyzed using grounded theory,creating a hierarchy of categories that represent what clients find important in therapy. From thehermeneutic analysis of the content of these categories, a list of principles was constructed to guide themoment-to-moment process of psychotherapy practice. The authors respond to the call for qualitativeoutcome studies and demonstrate how qualitative psychotherapy research can lead to empirically derivedprinciples that then can become the foundation of future research and psychotherapy integration efforts.Keywords: psychotherapy, principles, integrative, grounded theory, psychotherapy processIt is difficult to determine what is significant to clients abouttheir therapy experiences. Although some psychologists questionthe extent to which clients are able to provide valid informationabout their experiences (Howard, 1990; Kagan, 1990; Nicholson &Hogan, 1990; Nisbett & Wilson, 1977), our profession does seemto care about clients’ assessments of their psychotherapy experi-ences and seek their feedback both clinically and in researchendeavors (e.g., Kotkin, Daviet, & Gurin, 1996; Seligman, 1995).Psychotherapy outcome studies typically evaluate client changeusing self-report measures to assess changes in symptoms (e.g.,Beck, 1972; Derogatis, 1977; Horowitz, Rosenberg, Baer, Ureno& Villasenor, 1988). Clients’ reported perception of change thusguides our treatments, informs our theories, and ultimately sustainsour profession by creating a continued demand for our services.A variety of challenges to this mode of assessment, however,have been put forth. There are critiques that these measures do notassess types of change that are prized across therapy orientationsand, as such, generate poor assessments of humanistic and psy-chodynamic approaches (Bohart, Leitner, & O’Hara, 1998; Elliott,1998; Levitt, Stanley, Frankel, & Raina, 2005; Mander, 2000;Wallerstein, 2001). In addition, certain outcome measures havebeen found to privilege psychotherapy orientations most associ-ated with their theory of origin (e.g., Oei & Free, 1995), andmeasures do not appear to be selected to assess the different goalsof the therapy orientations being evaluated (Levitt, Stanley, et al.,2005). Finally, the research developed by using outcome measureassessments has been criticized, as it rarely provides informationon what therapists should do at the level of moment-to-momentprocess within the psychotherapy session and rarely assesses whatsymptom changes or their absence mean in clients’ lives (e.g.,Rennie, 1994b).As a result, some psychotherapy researchers have been callingfor qualitative approaches to inquiry as one path through whichresearchers can develop understandings of this in-session interper-sonal process of change. They argue that these methods allow afocus on subjectivity that is appropriate for understanding therapyand allow clients to articulate and contextualize elements ofchange that appear to be important in their own experience (e.g.,McLeod, 2000; Rennie, 1994b). Of note in this literature is theresearch examining significant psychotherapy moments.The Significant Moments LiteratureThis significant moment paradigm, largely developed by RobertElliott, has been used to heighten researchers’ understanding ofspecific events or therapy processes. A broad spectrum of themeshave been examined in interview studies, including clients’ de-scriptions of moments of misunderstanding (Rhodes, Hill, Thomp-son, & Elliott, 1994), insight events (Elliott et al., 1994), helpfulevents (Paulson, Truscott, & Stuart, 1999), problematic reactionpoints (Watson & Rennie, 1994), and helpful therapists’ interven-tions (Elliott, James, Reimschuessel, Cislo, & Sack, 1985). Sig-nificant events research has been conducted on both client andtherapist perspectives (e.g., Elliott & Shapiro, 1992; Martin &Stelmaczonek, 1988), and a task analytic study of significantmoments (Stiles et al., 1990) has generated problem resolutionscales.Within the body of research that examines descriptions of sig-nificant moments in psychotherapy, a variety of analytic methodshave been used. Elliott (1989) developed “comprehensive processanalysis” for the purpose of analyzing therapy sessions by codingthe text using a variety of coding systems. Using a differentapproach, Paulson et al. (1999) had client-participants categorizestatements from their interviews on what was helpful in therapy.Heidi Levitt, Mike Butler, and Travis Hill, Department of Psychology,University of Memphis.Mike Butler is now in the Counseling, Educational Psychology andResearch Department, University of Memphis.Travis Hill is now in private practice at Hill Counseling, Germantown,Tennessee.We thank the Social Science and Humanities Council of Canada fortheir support as well as Ze’ev Frankel.Correspondence concerning this article should be addressed to HeidiLevitt, Department of Psychology, University of Memphis, Memphis, TN38152. E-mail: [email protected] of Counseling Psychology Copyright 2006 by the American Psychological Association2006, Vol. 53, No. 3, 314 –324 0022-0167/06/$12.00 DOI: 10.1037/0022-0167.53.3.314314Other researchers have matched clients’ descriptions with categor-ical systems developed from the analysis to assess what works inpsychotherapy (e.g., Lietaer, 1992; Martin & Stelmaczonek, 1988;Wilcox-Matthew, Ottens, & Minor, 1997).Across the significant moment and other qualitative researchstudies, the factors identified as significant have differed. Forinstance, a review of prior literature by Elliott and James (1989)organized the research on clients’ psychotherapy experiences inthe following nine categories: clients’ intentions, feelings, style ofrelatedness, style of relating, central concerns, therapists’ inten-tions, therapists’ characteristics, therapeutic impacts, and helpfulaspects of therapy. Other researchers have identified similar ele-ments of therapy but often using different labels. For instance,different researchers have identified processes of reflexive self-examination as a central function of the psychotherapy process(e.g., Martin & Stelmaczonek, 1988;