Crying in psychotherapy among Israeli patients and its relation to the working alliance, therapeutic change and attachment style

Abstract

Patients' crying in psychotherapy can, at times, be an indicator of a healing process and reflect patients' engagement. This study explored the relationships between Israeli patients' crying in therapy, the working alliance, therapeutic change and attachment styles, using similar procedures to the ones used by Genova et al. (2020; Psychotherapy, 58, 160) in a recent investigation of Italian patients. One hundred and thirteen patients completed an online survey in Hebrew about crying in therapy and self-report measures assessing the working alliance, therapeutic change and attachment styles. Our findings revealed that self-reported working alliance was related to the patients' perceptions of their therapist responding to their most recent crying episode with support and compassion. Therapeutic change was associated with a tendency to cry in therapy and higher instances of crying in therapy during the last year. Patients with anxious-preoccupied attachment styles had more faith that crying would lead to being understood by their therapist. Dismissive-avoidant attachment style was related to higher likelihood of feeling like the most recent crying episode helped the patient understand things that they did not understand before and feel like their tears expressed things that words could not. Further, fearful-avoidant, anxious-preoccupied and dismissive-avoidant attachment styles were all related to stronger faith in the therapy relationship strengthening after crying. These findings are in line with, and expand on, Genova et al.'s (2020; Psychotherapy, 58, 160) findings regarding the therapy alliance, crying in therapy and attachment styles. Implications for the relationships between patient attachment style, therapy alliance, therapeutic change and crying in therapy are discussed.

“Window of opportunity”: Clients’ experiences of crying in psychotherapy and their relationship with change, the alliance, and attachment.

“…Regarding the direct relationship between clients’ crying experiences in therapy and the working alliance, our findings regarding the connection between clients experiencing their therapist as responding with compassion and support to their tears and the therapeutic alliance are consistent with both Genova et al (2021) and Katz et al (2022), providing further cross-cultural evidence for this potentially bidirectional relationship. That is, clients who experience their therapist as responding with support and compassion to their tears might experience a boost in their alliance, or a stronger alliance might impact the way that a client experiences how supportive or compassionate their therapist is to their tears.…”

“…Further, clients perceiving their crying in therapy as an authentic and insightful moment, as well as feeling more understood and connected with their therapist after they had cried, was found to be correlated with reports of greater improvement in therapy. In a study using a similar methodology but with a sample of Israeli clients, Katz et al (2022) found that a higher number of reported patients' crying episodes in treatment was linked to positive therapeutic change. However, the authors note previous evidence that client crying in therapy's relation to the alliance or outcome is often not necessarily about quantity (i.e., the number of crying episodes) but rather about quality of that experience (i.e., the way these crying episodes are experienced and/or processed with the therapist).…”

“…Items of the Crying in Therapy were in part derived from the Adult Crying Inventory (Vingerhoets, 2001), a measure of crying in daily life, as well as the Therapist Crying in Therapy Survey (Blume-Marcovici, 2012;Blume-Marcovici et al, 2013), which measures therapists' crying behavior in treatment. For full psychometric properties and a detailed description of the crying in therapy survey, see Genova et al (2021) and Katz et al (2022). After completing some demographic questions, participants are asked about general crying experiences outside of therapy in the last month and year, crying tendency (on a 10-point Likert scale ranging from I have never cried to I cry very easily), and changes in emotional and physical states (e.g., tension, relaxation, sadness, depression, in control, relief and happiness) after crying (Vingerhoets, 2001).…”

“…With that in mind, recent studies have begun examining whether attachment styles or more generally being securely versus insecurely attached are correlated with clients’ experiences of crying in therapy. Katz et al (2022), for example, found that clients who rated themselves as higher on preoccupied attachment style tended to have greater belief that crying lead them to being better understood by their therapist, while clients who ranked themselves higher on dismissive attachment style were more likely to report that crying helped them better understand themselves, as well as that crying helped them express things that were beyond words. Further, insecurely attached clients (regardless of specific style) tended to have greater confidence in the therapeutic relationship strengthening after they had cried, compared to securely attached clients who tended to place less importance on crying as it relates to their relationship with the therapist, and who generally tended to view crying in therapy as less intense.…”

“…With that in mind, we set out to examine crying experience in therapy, reported change, the working alliance, and attachment security. We hypothesized that (1) Client positive emotional and cognitive experiences reported postcrying in therapy will be related to reported positive change in therapy, while the opposite will occur for negative experiences after crying; (2) Clients’ reporting that they felt their therapist reacted to their tears with support and compassion will be related to a better working alliance; (3) Other client emotional and cognitive postcrying experiences will be related to the working alliance, particularly feeling that crying was a moment of genuine vulnerability and feeling more confident in reaching therapy goals after crying (Genova et al, 2021); (4) Self-reported attachment insecurity will be positively associated with patients’ tendency to view their own crying experiences in therapy as both more challenging but also potentially more valuable (Genova et al, 2021; Katz et al, 2022).…”