Therapeutic Collaboration Coding System

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The development of therapeutic

collaboration in a good outcome case of
person-centered therapy
a a a
Eugénia Ribeiro , Catarina Fernandes , Beatriz Santos , António
a a b b
Ribeiro , Joana Coutinho , Lynne Angus & Leslie Greenberg
a
School of Psychology, University of Minho, Braga, Portugal
b
Department of Psychology, York University, North York, Ontario,
Canada
Published online: 16 Apr 2014.
To cite this article: Eugénia Ribeiro, Catarina Fernandes, Beatriz Santos, António Ribeiro, Joana
Coutinho, Lynne Angus & Leslie Greenberg (2014) The development of therapeutic collaboration in
a good outcome case of person-centered therapy, Person-Centered & Experiential Psychotherapies,
13:2, 150-168, DOI: 10.1080/14779757.2014.893250
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The development of therapeutic collaboration in a good outcome case

of person-centered therapy
Eugénia Ribeiroa*, Catarina Fernandesb, Beatriz Santosa, António Ribeirob,
Joana Coutinhoc, Lynne Angusd and Leslie Greenbergd
a
School of Psychology, University of Minho, Braga, Portugal; bSchool of Psychology, University of
Minho, Braga, Portugal; cSchool of Psychology, University of Minho, Braga, Portugal;
d
Department of Psychology, York University, North York, Ontario, Canada
(Received 29 April 2013; final version received 7 February 2014)
This paper explores the development of therapeutic collaboration in Person-

Centered Therapy (PCT). It presents a good outcome case – “Mary” – selected
from York I Depression Study, treated with PCT. The study examined how therapist
and client worked together throughout the therapy, using the Therapeutic
Collaboration Coding System (TCCS). The TCCS assumes that effective therapeu-
tic collaboration occurs within the client’s therapeutic zone of proximal develop-
ment (TZPD), defined as the distance between the actual and the potential client’s
developmental level. It consists of a transcript-based method by which therapist’s
interventions and client’s responses are analyzed on a moment-to moment basis.
Two independent trained judges coded 15 sessions of this case, using the TCCS.
Results showed that the therapeutic dyad worked most of the time within the
client’s TZPD, thus suggesting a collaborative pattern throughout the therapy
process. In addition, the results showed that the client proactively interacted with
the therapist, moving forward in her TZPD.
Keywords: therapeutic collaboration; Person-Centered Therapy; good outcome; case
study
Die Entwicklung therapeutischer Zusammenarbeit in einer

Personzentrierten Therapie anhand eines Falles mit gutem Outcome
Dieser Artikel untersucht die Entwicklung therapeutischer Zusammenarbeit in der
Personzentrierten Therapie (PCT). Ein Fall mit gutem Outcome wird vorgestellt –
“Mary” – ausgewählt aus der York I Depression Study (Greenberg & Watson, 1998),
behandelt mit PCT. Die Studie untersucht mit dem Therapeutic Collaboration
Coding System (TCCS), wie Therapeut- und Klient-Person während der Therapie
zusammenarbeiten. Das TCCS geht davon aus, dass effektives therapeutisches
Zusammenarbeiten innerhalb des Bereiches proximaler Entwicklung der Klient-
Person geschieht (TZPD). Proximale Entwicklung wird definiert als die Distanz
zwischen dem aktuellen und dem potentiellen Entwicklungsniveau des Klienten. Sie
besteht aus einer transkript-basierten Methode, mit deren Hilfe die Interventionen der
Therapeut-Person und die Antworten der Klient-Person auf der Basis von Moment-zu-
Moment analysiert werden. Zwei unabhängige, geschulte Beurteilende kodierten 15
Sitzungen dieses Falles und benutzten dabei das TCCS. Die Resultate zeigten, dass die
therapeutische Dyade meistens innerhalb des TZPD der Klient-Person arbeitete, was
ein Muster der Zusammenarbeit während des Therapieprozesses nahelegt. Außerdem
*Corresponding author. Email: eugenia@psi.uminho.pt
© 2014 World Association for Person-Centered & Experiential Psychotherapy & Counseling
Person-Centered & Experiential Psychotherapies 151
zeigten die Resultate, dass die Klient-Person proaktiv mit der Therapeut-Person inter-
agierte und sich in ihrem TZPD steigerte.
El desarrollo de la colaboración terapéutica en un caso de buenos

resultados de terapia centrada en la persona
este trabajo explora el desarrollo de colaboración terapéutica en la terapia centrada
en la persona. Presenta un caso con buenos resultados, “Mary”, seleccionado de
Estudio de la depresión de York (Greenberg & Watson, 1998), tratado con el
enfoque centrado en la persona. El estudio examino como el terapeuta y el
consultante trabajaron juntos a traves del proceso de terapia, utilizando el sistema
de codificación de la colaboración terapéutica. Este sistema asume que la
colaboración terapéutica efectiva tiene lugar dentro de la zona de desarrollo de
proximidad del consultante, definida como la distancia entre el nivel potencial de
desarrollo del cliente actual y el potencial. Consiste en un método basado en la
transcripción mediante el cual las intervenciones del terapeuta y las respuestas del
consultante se analizan momento a momento. Dos jueces independientes y entre-

nados codificaron 15 sesiones de este caso usando dicho método. Los resultaron
mostraron que la diada terapéutica trabajo la mayor parte del tiempo dentro de la
zona terapéutica de desarrollo de proximidad del consultante, por lo tanto sugir-
iendo un patrón colaborativo a lo largo del proceso. Sumado a esto los resultados
mostraron que el consultante interactuó proactivamente con el terapeuta, yendo mas
allá de su zona.
Le développement de la collaboration thérapeutique dans un cas de

thérapie centrée sur la personne à bons résultats
Cet article explore l’évolution de la collaboration thérapeutique dans une thérapie
centrée sur la personne (ACP). Il présente un cas à résultats importants - «Marie» -
choisi dans le York I Étude sur la Dépression (Greenberg et Watson, 1998), qui a
suivi une thérapie ACP. L’étude examine la façon dont le thérapeute et la cliente
travaillent ensemble tout au long de la thérapie, en utilisant le Système de Codage de
la Collaboration Thérapeutique (SCCT). Le SCCT suppose que la collaboration
thérapeutique efficace se produit dans la zone thérapeutique de développement
proximale du client (ZTDP), définie comme la distance entre le niveau de
développement actuel et potentiel du client. Il se compose d’une méthode basée
sur la transcription par écrit où les interventions du thérapeute et les réponses des
clients sont analysée d'instant en instant. Deux juges indépendants et formés ont codé
15 séances de ce cas, à l’aide de la SCCT. Les résultats ont démontrent que la dyade
thérapeutique travaille à l’intérieur de la ZTDP de la cliente pour la plupart du temps,
suggérant ainsi un modèle de collaboration tout au long du processus. En outre, les
résultats démontrent que la cliente interagie de manière proactive avec son
thérapeute, avançant à l’intérieur de sa ZTDP.
O Desenvolvimento da Colaboração Terapêutica num caso de sucesso de

Terapia Centrada na Pessoa
O presente artigo explora o desenvolvimento da colaboração terapêutica em Terapia
Centrada na Pessoa. (TCP). Apresenta um caso de sucesso clínico – “Mary” –
selecionado do York I Depression Study (Greenberg & Watson, 1998), e seguido
em TCP. O estudo analisou como a terapeuta e a cliente trabalharam juntas ao longo
da terapia, usando o Sistema de Codificação da Colaboração Terapêutica (SCCT). O
SCCT assume que a colaboração terapêutica efetiva ocorre dentro da Zona
152 E. Ribeiro et al.
terapêutica de desenvolvimento proximal da cliente (ZDPT), definida como a

distância entre o nível de desenvolvimento atual e o nível de desenvolvimento
potencial da cliente. Este sistema consiste num método baseado na transcrição das
sessões, em que as intervenções da terapeuta e as respostas da cliente são analisadas
momento a momento. Dois juízes treinados com o SCCT codificaram de modo
independente 15 sessões deste caso, usando o SCCT. Os resultados mostraram que
a díade terapêutica trabalhou a maior parte do tempo dentro da ZDPT da cliente,
sugerindo um padrão de interação colaborativa ao longo da terapia. Além disso, os
resultados mostraram que a cliente interagiu proactivamente com a terapeuta,
avançando na sua ZDPT.
Introduction
The present study aimed to analyze how the therapeutic collaboration develops as the
therapy of a good outcome case of Person-Centered Therapy (PCT) progresses. We used a
specific concept of therapeutic collaboration, which we assume as being trans-theoretical
and that we will elaborate later. Convergences and divergences with the Person-Centered
perspective are presented along with the description of our theoretical conceptualization of
collaboration and change in psychotherapy. Specifically, our focus on the contribution of
the therapist’s challenging interventions for change may be in conflict with Rogers’ theory
of change and is also discussed.
Therapeutic relationship
The therapeutic relationship plays an important role in the client’s experiences of change
in psychotherapy. References to Rogers’ (1959) understanding of the importance of the
therapeutic relationship often focus on the well-known therapeutic conditions of empathy,
unconditional positive regard and congruence. However, from Rogers’ perspective “ther-
apy is not a matter of doing something to the individual, or of inducing him to do
something about himself. It is instead a matter of freeing him for normal growth and
development…” (Rogers, 1942, p. 29). Thus, in addition to Rogers’ emphasis on thera-
pists’ behaviors and attitudes (Watson & Kalogerakos, 2010), he assumed that they are
intertwined with the client’s experience.
The mutual influence of both clients and therapists on the therapeutic interaction is
also assumed to be crucial by renowned authors on alliance literature (e.g. Bordin, 1979;
Horvath, 2013; Muran, Safran, & Eubanks-Carter, 2010). Indeed, although Rogers never
talked of therapeutic alliance, Bordin (1994) recognized the influence of Rogers’
emphasis on the healing power of the therapeutic relationship in his work on therapeutic
alliance.
In this paper we adopt the term “alliance” to refer to the collaborative negotiation of
the therapeutic work between therapist and client and further suggest the concept of
therapeutic collaboration, understood as a micro process of the therapeutic alliance.
In order to fully understand the dynamics of the relationship between the alliance and
outcome, E. Ribeiro, A. P. Ribeiro, Gonçalves, Horvath, and Stiles (2013) proposed a
therapeutic collaboration-change model, elaborating on how the interaction between
therapist and client is articulated with the client’s change on a moment-to-moment
level. This model is the conceptual basis of the Therapeutic Collaboration Coding
System (TCCS), developed by the same authors to micro-analyze the therapeutic colla-
boration. The aim of this paper is to investigate how therapeutic collaboration develops
throughout a good outcome case of PCT, using the TCCS.
Therapeutic collaboration-change model: therapeutic zone of proximal development

The therapeutic collaboration-change model provides a conceptual framework to under-
stand, on a moment-to-moment level, how therapeutic collaboration contributes to the
client’s change in therapy (E. Ribeiro et al., 2013). With the Vygotskian concept of “zone
of proximal development (ZPD)” in mind, E. Ribeiro et al. (2013) proposed that both
collaboration and change have a developmental nature, being connected in a continuous
and dynamic interchange within the client’s Therapeutic Zone of Proximal Development
(TZPD).
Vygotsky (1978) defined ZDP as “the distance between the actual developmental level
as determined by independent problem solving and the level of potential development as
determined through problem solving under adult guidance or in collaboration with more
capable peers” (p. 86). Leiman and Stiles (2001) applied this concept to therapy, by
suggesting that the “ZDP can be understood as the segment of the assimilation continuum
of problematic experiences within which the client can proceed from one level to the next
with the therapist’s assistance” (p. 315). Following Leiman and Stiles’s (2001) adaptation
of the ZDP to therapy, E. Ribeiro et al. (2013) conceptualized change in psychotherapy as
a form of development, which takes place within the TZPD. This zone is defined as the
distance between the client’s actual development level and his/her potential developmental
level that can be achieved in collaboration with the therapist.
At the beginning of therapy, the actual level is manifested through the “problem” that
led the client to ask for help in therapy as well as his/her difficulty in overcoming it
without help. From the perspective of PCT, it would mean that the client is “in a state of
incongruence, being vulnerable and anxious” (Rogers, 1957, p. 95) which blocks his self-
actualizing tendency. In turn, the potential development level is defined by the changes
that the client is able to accomplish with the therapist’s help. Thus the therapist’s role is
“to assist the individual to grow, so that he can cope with the present problem and with
later problems in a better integrated fashion” (Rogers, 1942, p. 28).
The concept of TZPD emphasizes two crucial ideas: (1) the client’s change is under-
stood as a dynamic process of empowerment in which the client goes from a maladaptive
frame of reference to a more functional one, and (2) by contributing to the clarification of
the client’s potential change level and by facilitating the client’s development through the
TZPD, the therapist provides a scaffolding framework for the client’s self-exploration and
reflection. Therefore, from the beginning of therapy, therapists seek to provide an
environment in which new experiences can be tolerated and considered, hence gradually
the client’s TZPD would be (re)constructed in the context of a continuously collaborative
and responsive interaction (E. Ribeiro et al., 2013). We believe that, in terms of PCT, this
therapeutic climate will occur if the essential conditions stated by Rogers (1957) are
assured.
Therapeutic collaboration as a balance within the therapeutic zone of proximal

development
The concept of the TZPD provides a theoretical background to study the interdependence
between the client’s change process and the resources provided by the therapeutic context,
namely the collaborative interaction between therapist and client. From the beginning of
therapy, therapist and client join together in a collaborative interaction that, in our view,
requires them to keep awareness of their own and the other’s ongoing internal experi-
ences, allowing them to move forward or backwards in the TZPD. The therapist needs to
be responsive to the client’s needs: on the one hand the client needs his/her experience of
suffering to be understood, and, on the other hand, the client needs to improve and move
forward in life. The ability of the therapist to empathically attune to the client’s experi-
ences is crucial to provide a safe and trusting therapeutic space wherein the client’s
experiences are disclosed, understood and reconstructed (Angus & Greenberg, 2011).
Taking the previous ideas into account, E. Ribeiro et al. (2013) suggested two main
therapist activities crucial for the development of therapeutic collaboration: supporting the
client’s frame of reference, by trying to empathically understand the client’s experiences
and emphatically challenging the client’s frame of reference. Therefore, the therapist’s role
in facilitating client’s change involves working within a therapeutic arena, wherein a client
feels comfortable enough to explore and experience a different perspective on self or
others. Both of these therapist actions help to promote the change that the client wishes to
achieve and/or elaborate on processes of change that have already begun. Thus, the
therapist plays a crucial role in promoting the movement from the client’s current level
of understanding about problem issues to a more adaptive perspective on self and others –
a potential level of development – by being able to identify where and how to guide the
client towards change.
The degree to which a therapist’s intervention operates within a client’s TZPD should
however be validated by the client’s immediate response. The client’s affirmative valida-
tion of the therapist’s intervention indicates that the therapist is working within the TZPD,
by either perceiving the client’s need for supporting and then promoting the client’s
experience of safety, or by identifying the client’s readiness for change and then promot-
ing the client’s experience of tolerable risk (E. Ribeiro et al., 2013).
If the client does not confirm the therapist’s intervention, it may mean that the
therapist is working outside the TZPD, indicating either disinterest or an intolerable risk
experience for the client. In some way, we may assume that the therapist’s intervention is
wrong when it ignores or does not fit the client’s experience of vulnerability or potential to
grow. In terms of the therapist, this kind of interaction may mean that the therapist is
behind the client’s movement towards a new TZPD, is overly redundant in his/her
interventions, and may not be responsive to the client’s readiness for change.
Alternatively, a client’s lack of affirmation may indicate that a therapist is too far ahead
of the client in terms of moving into the TZPD, resulting in an experience of intolerable
risk or anxiety for the client. An ambivalent client response may indicate that the
therapist’s interventions are working at the leading edge of the client, placing him/herself
behind or beyond the client’s current comfort level, in reference to the TZPD. Figure 1
shows a diagram of the TZPD, taking the therapeutic collaboration-change model as
reference.
Person-centered therapy: which balance in the therapeutic collaboration?

Rogers (1959) proposed that all human beings have a positive, constructive and social
nature. When the client asks for help in therapy, she/he brings the problem of being
limited in her freedom and self-determination, showing an imbalance between hetero-
nomy and autonomy (Kensit 2000). The aim of PCT is to “help the client to unravel the
‘personal theory’ which he has constructed around his own experiencing” (Mearns &
Thorne, 1999, p. 5), creating the opportunity to increase inner congruence. According to
the theoretical foundation of PCT the relationship between therapist and client becomes
therapeutic when the client’s psychological freedom emerges, that is, when the client
perceives and experiences the therapist’s nondirective trust (Bozarth, 2012; Moon & Rice,
Figure 1. Segment of the therapeutic developmental continuum showing the therapeutic zone of
proximal development (TZPD). Note. From: How collaboration in therapy becomes therapeutic:
The therapeutic collaboration coding system, by E. Ribeiro et al. (2013). Adapted with permission.
2012) and regains her own autonomy. The therapist’s nondirective attitude is intended to
create an interactive climate in which the client feels free to pursue his/her own direction
and comfortable to acknowledge and express his/her perceptions of the therapist’s beha-
vior and/or interventions, if he/she feels it is important. Through the core conditions of
unconditional positive regard, empathy and congruence, proposed by Rogers (1959, p.
213), the person-centered therapist creates the necessary conditions to facilitate the client’s
movement towards self-actualization that highlights the agency of the client, in the change
process.
Taking this into account, we wondered if it would be inconsistent with the nondir-
ective and trustful attitude adopted by person-centered therapists, if they challenged their
client’s frame of reference to facilitate moving forward within the TZPD, as suggested by
E. Ribeiro et al. (2013). The authors assume that both supporting and challenging
interventions can be experienced as empathic actions by clients, if they are responsive
to the client’s needs and experiences as perceived by the therapist. Furthermore, in this
model, the client has the last word, either validating or invalidating the therapist’s actions.
We believe that even when challenged, the client is still free to accept or to refuse the
therapist’s invitation to move forward in the self-healing process. In line with a number of
psychotherapy researchers and clinicians (e.g. Lambers, 2011; Moon & Rice, 2012;
Murphy, Cramer, & Joseph, 2012) we agree that enhancing a client’s trust in her own
capacity for change is essential for effective psychotherapy and frees the therapist to
engage in a mutual and collaborative relationship that balances the implementation of both
supportive and challenging interventions.
Based on this model of therapeutic collaboration, the present study was implemented
to provide a fuller understanding of how one person-centered therapist and her client
expressed a sense of freedom and trust in each other in therapy sessions that resulted in
overall successful treatment outcomes.
The present study

In the present study we analyzed two main questions: (1) how does therapeutic collabora-
tion develop as the therapy of a good outcome case of PCT progresses?, and (2) how does
the client’s change emerge in the context of therapeutic collaboration?
Thus this work refers to a case study aiming to analyze in fine-grained detail the
development of therapeutic interaction in the real context of the therapy process. In this
exploratory study, we adopted a theory-building perspective (Stiles, 2009).
Method
Case analysis
The focus of this study is a therapeutic dyad formed by a depressed client and a person-
centered therapist, selected from the York I Depression Study (Greenberg & Watson,
1998).
Since the major goal of this case study was to reach an in-depth understanding of the
therapist’s and the client’s mutual contribution to their therapeutic collaboration, the main
unit of analysis involved both the participants.
The client
When Mary (a pseudonym) asked for help, she was 38 years old, married, and had three
children. Her husband spent a lot of time away from home on business, which made her
feel extremely responsible for everything around her. She felt very vulnerable expressing
lack of control, mainly with her children. She was afraid of being like her father, who used
to lose control and physically assaulted her as child. She reported experiencing significant
depressive symptoms before entering therapy, scoring 24 on the Beck Depression
Inventory (BDI). Mary’s case was selected for this study on the basis of significant
symptomatic change evidenced on pre–post standardized assessment measures. Her pre-
therapy BDI score of 24 dropped to 7 at therapy termination. A Reliable Change Index
(RCI) analysis of her BDI pre- to post-test change scores classified Mary as having met
criteria for recovered (i.e. passed both a BDI cut-off score of 11.08 and RCI criteria) at
treatment termination (see Jacobson & Truax, 1991).
The therapist
The therapist who conducted the therapeutic process was a female graduate student in
clinical psychology. She received 24 weeks of training in PCT according to the manual
devised for the York I Depression study (Greenberg, Rice, & Watson, 1994). She also
attended weekly supervision sessions. A check of treatment adherence was conducted in
the original study (Greenberg & Watson, 1998).
Treatment
According to the manual of Greenberg et al. (1994), PCT is based on the three funda-
mental relational conditions proposed by Rogers (1951): congruence, unconditional
positive regard, and empathy. Participating therapists were trained in PCT using manuals
developed specifically for this purpose (Greenberg et al., 1994) wherein exploratory
empathic responses to promote deepening of client experiencing as well as interchange-
able empathic responses to convey understanding were implemented in the context of 16
weekly therapy sessions. An expert in PCT supervised all PCT therapists weekly.
Researchers
The coding procedure involved two judges and an auditor. The second author coded all
sessions and the third author coded 30% of the sessions. The judges were both 23-year-old
women in their final master year in clinical psychology. Prior to participating in this study,
the judges received intensive training in the TCCS and they both studied in depth
literature relating to PCT. The first author supervised the training and audited the coding.
Measures
Beck Depression Inventory (BDI)
The BDI is a 21-item self-report instrument assessing symptoms of depression (Beck,
Steer, & Carbin, 1988; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). In this study,
the BDI was administered pre- and post-therapy in order to measure the improvement in
symptoms.
Therapeutic Collaboration Coding System (TCCS)

The TCCS is a transcript-based coding system designed to micro-analyze the therapeutic
collaboration, as conceptualized by E. Ribeiro et al. (2013). This coding system takes each
client and therapist speaking turn as the unit of analysis, which is evaluated in the context
of the other’s previous speaking turn (immediate context) and all previous client–therapist
interaction during the session (overall context). Before coding the therapist interventions
and client responses, the judges must discuss the client’s frame of reference in order to
establish a consensual definition of what they will code as the client’s problem or the
client’s innovation.1 Based on their reading of the therapeutic dialogue of the early
sessions, the judges identify quotations of the client’s and therapist’s utterances referring
to the client’s current problems and the changes that client wants. Thereafter the judges
discuss and define the list of problems and the potential innovations. Therapist interven-
tions are coded according to the Supporting or Challenging categories (Table 1) and client
responses are coded according to the Validation, Invalidation or Ambivalence categories
(Table 2). Validation and Invalidation responses are interpreted as reflecting different
kinds of client experiences. Thus, Validation may indicate a Safety or a Tolerable risk
experience, depending on the focus (problem or innovation) and the level of elaboration
of the client’s response. Invalidation may indicate a Disinterest or an Intolerable risk
experience, depending on the lack of involvement or the anxiety manifested by the client’s
response. Connections between the therapist’s intervention and the client’s response
categories are interpreted as reflecting the position of the therapeutic exchange relative
to the TZPD. TCCS allows us to describe 18 alternative types of therapeutic exchanges
Table 1. Therapist intervention coding subcategories.
Supporting subcategories Definitions
Reflecting The therapist reflects the content, meaning or feeling present in

the client’s words. He or she uses his/her or client’s words but
doesn’t add any new content in the reflection, asking for an
implicit or explicit feedback.
Confirming The therapist makes sure he/she understood the content of the
client’s speech, asking the client in an explicit and direct
mode.
Summarizing The therapist synthesizes the client’s discourse, using his/her
own and client’s words, asking for feedback (implicit or
explicit)
Demonstrating interest/attention The therapist shows/affirms interest on client’s discourse.
Open Questioning The therapist explores clients experience using open questioning.
The question opens to a variety of answers, not anticipated
and/or linked to contents that the client doesn’t reported or

only reported briefly. This includes the therapist asking for
feedback of the session or of the therapeutic task.
Minimal encouragement The therapist makes minimal encouragement of the client’s
speech, repeating client’s words, in an affirmative or
interrogative mode (ambiguous expressions with different
possible meanings aren’t codified, like a simple ‘Hum… hum’
or ‘ok’).
Specifying information The therapist asks for concretization or clarification of the
(imprecise) information given by the client, using closed
questions, specific focused questions, asking for examples.
Challenging subcategories Definitions
Interpretating The therapist proposes to the client a new perspective over his or
her perspective, by using his or her own words (instead of the
client’s words). There is, though, a sense of continuity in
relation to the client’s previous speaking turn.
Confronting The therapist proposes to the client a new perspective over his or
her perspective or questions the client about a new perspective
over his or her perspective. There is a clear discontinuity (i.e.
opposition) in relation to the client’s speaking turn.
Inviting to adopt a new The therapist invites (implicitly or explicitly) the client to
perspective understand a given experience in an alternative way.
Inviting to put into practice a The therapist invites the client to act in a different way, in the
new action session or out of the session.
Inviting to explore hypothetical The therapist invites the client to imagine hypothetical scenarios,
scenarios i.e. cognitive, emotional and/or behavioral possibilities that are
different from the client’s usual way of understanding and
experiencing.
Changing level of analysis The therapist changes the level of the analysis of the client’s
experience from the descriptive and concrete level to a more
abstract one or vice-versa.
Emphasizing novelty The therapist invites the client to elaborate upon the emergence
of novelty.
Debating client’s beliefs The therapist debates the evidence or logic of the client’s beliefs
and thoughts.
Tracking change evidence The therapist searches for markers of change, and tries to
highlight them.
Note. From: How collaboration in therapy becomes therapeutic: The therapeutic collaboration coding system,
by E. Ribeiro et al. (2013). Adapted with permission.
Table 2. Client response coding subcategories.
Validation subcategories Definitions
Confirming The client agrees with the therapist’s intervention, but

does not extend it.
Giving information The client provides information according to the
therapist’s specific request.
Extending The client not only agrees with the therapist
intervention, but expands it (i.e. goes further).
Reformulating oneself perspective The client answers the therapist’s question or reflects
upon the therapist’s prior affirmation and, in doing
so, reformulates his or her perspective over the
experience being explored.
Clarifying The client attempts to clarify the sense of his or her
response to the therapist prior intervention or clarify
the sense of the therapist’s intervention itself.
Invalidation subcategories Definition
Expressing confusion Client feels confused and/or states his or her inability
to answer the therapist’s question.
Focusing/Persisting on the dominant Client persists on looking at a specific experience or
maladaptive self-narrative topic from his or her standpoint.
Defending oneself perspective and/or Client defends his/her thoughts, feelings, or behavior
disagreeing with therapist’s intervention by using self-enhancing strategies or self-justifying
statements.
Denying progress Client states the absence of change (novelty) or
progress.
Self-criticism and/or hopelessness Client is self-critical or self-blaming and becomes
absorbed in a process of hopelessness (e.g. client
doubts about the progress that can be made)
Lack of involvement in response Client gives minimal responses to therapist’s efforts to
explore and understand client’s experience.
Shifting topic Client changes topic or tangentially answers the
therapist
Topic/focus disconnection The client persists in elaborating upon a given topic
despite the therapist’s efforts to engage in the
discussion of a new one.
Non meaningful storytelling and/or Client talks in a wordy manner or overly elaborates
focusing on others’ reactions non-significant stories to explain an experience and/
or spends an inordinate amount of time talking about
other people.
Sarcastic answer The client questions therapist’s intervention or is ironic
towards therapist’s intervention.
Note. From: How collaboration in therapy becomes therapeutic: The therapeutic collaboration coding system,
by E. Ribeiro et al. (2013). Adapted with permission.
that can result from such connections and their relation to the TZPD. These therapeutic
exchanges range from interactions within the TZPD, reflecting the client actual develop-
ment level (e.g. Supporting problem – safety) or the client potential developmental level
(e.g. Challenging – tolerable risk), to interactions in the limit (e.g. Challenging – ambiva-
lence, i.e. validation and then invalidation in the same client speaking turn) or without the
TZPD (e.g. Challenging – intolerable risk).
Previous studies using the TCCS (E. Ribeiro et al., 2013; A. P. Ribeiro et al., 2013)
showed good reliability with mean Cohen’s Kappa values of .92 for the therapist
interventions (based on N = 3,234 utterances) and .93 for client responses (based on
N = 3,234 utterances).
Procedures
Coding procedures
The TCCS was used to code 15 therapy session-transcripts – all sessions except for
session 6 which was missing from the transcript database. The coding procedure required
two judges and involved four steps: (1) consensual definition of client problem and the
expected innovation, (2) independent coding, (3) disagreement resolution through con-
sensus, and (4) auditing of codifications. Until the end of the coding process the judges
were unaware of the case’s clinical outcome.
As stated above, the first step of coding with the TCCS involved a meticulous reading
of the initial sessions in order to reach a consensual definition of the client’s experience of
self-incongruence or vulnerability. Based on the client’s verbal expressions, the two
judges agreed that Mary’s manifestations of incongruence or vulnerability included (1)

the experience of uncertainty in several dimensions of her life, (2) the feeling of being
responsible for everything around her, and (3) the feeling of being extremely vulnerable
when expressing distressing emotions, especially with her children.
Gonçalves, Matos, and Santos (2009) defined innovation as the emergence of some-
thing new (e.g. actions, feelings, thoughts, meanings) which is an exception to the rule
underlying the problematic self-narrative. Based on this definition, which is adopted in the
TCCS, judges considered that Mary’s innovations would be coded when she accepted the
therapist’s challenging of her vulnerabilities or when she elaborated on exceptions to
them, growing in her self-actualizing tendency. Therefore, the judges expected to code as
innovation the client’s signs of trust in her own actions or the client’s feelings of
emotional regulation. So whenever the client showed confidence about what she said
and the actions she took, or when she could express her emotions in a regulated way, it
was coded as an innovation.
Both judges independently coded 30% of the transcripts of the sessions, discussing
disagreements until they reached a consensual coding, which was audited for a final
decision. The mean percentage of agreement for the first 30% of a session was 87% for
therapist’s interventions and 88% for client’s responses. Since the percentage of agree-
ment was high and most of the time the judges proved to be in agreement with each other
and the auditor when discussing encodings, the second author continued to code the last
70% of sessions. The auditor was involved in the coding decision of 50% of sessions,
reviewing and discussing disagreements with the judges.
Results
Development of Therapeutic collaboration throughout the therapy process
The descriptive analysis of therapeutic collaboration considers the percentage of each category
of Therapist’s Interventions; percentage of each Client’s Experiences as indicated by her
responses and percentage of therapeutic exchanges within, on the limit, and outside the TZPD.
Figure 2 shows a higher percentage of Supporting Problem intervention (SP) in all
sessions throughout the therapy process, in comparison with the less frequent interventions
of Supporting Innovation (SI) and Challenging (CH). Although CH appears to have been,
on average, less frequent then SP, it should be noted that they occurred more frequently
than SI in sessions 1, 5, 7, 8, 9. As such, in spite of the higher prevalence of SP overall, it
100
80
60 Supporting problem
40 Supporting innovation
20 Challenging
0
1 2 3 4 5 7 8 9 10 11 12 13 14 15 16
Figure 2. Percentage of category of therapist’s interventions throughout the therapy process.
100%
80% disinterest
amb. -tolerable risk
Index
60%
40% safety
20% tolerable risk
0%
amb. -safety
1 2 3 4 5 7 8 9 10 11 12 13 14 15 16
Sessions intolerable risk
Figure 3. Percentage of each category of client’s responses throughout the therapy process.
appears that the PCT therapist encouraged the client to work on the potential level of
development, and then supported the emerged innovation, in the middle phase of therapy.
Figure 3 shows a higher percentage of client’s Safety experience (S), which is
indicated by client’s validation of the therapist’s interventions, either confirming or giving
information on the explored topic (problem or innovation). Apart from the client’s
responses indicating Tolerable risk (TR) and Intolerable risk experiences (IR), all other
possible client responses were close to 0%. From session 11 to session 13 there is a clear
increase in client responses indicating TR. Over the sessions, there is a low but stable
percentage of client responses invalidating the therapist’s interventions indicating IR.
These findings indicate that therapeutic exchanges over the sessions were essentially
collaborative. In most of the therapeutic interactions the dyad worked within the TZPD,
ranging from 90% in the early sessions to 100% in the final phase of the therapy.
Although client invalidations of the therapist’s interventions were low, the presence of
this kind of response until session 12 indicates that sometimes the client experienced IR,
i.e. the dyad worked without the TZPD.
The following clinical vignette illustrates the most frequent therapeutic exchange
throughout the process (Supporting problem – Safety), which indicates that the client
validated the therapist’s intervention and both worked within the TZPD, close to the
client’s actual level of development.
Vignette 1(session1): supporting problem – safety
Cl: yeah (laughter) yes, I find it hard to do at night. (...) but at night I find it especially
difficult because there’s nothing, it’s quiet (laughs), you know, you are alone with your
thoughts and it tends to be a bit ah overwhelming.
T: yeah, so at night time it’s a lot harder+ then during the day. (SP)
Cl: yes + , that’s so far..in the past two weeks anyway (laughs). (S: giving information)
The way change emerged throughout the therapy process

Since this is a good outcome case, we decided to analyze how change emerged throughout
the therapy process. According to the therapeutic collaboration-change model (E. Ribeiro
et al. 2013) CH would be the privileged mode of intervention that a therapist would
employ to encourage the client to move towards change. Figure 2 shows that, in this
clinical case, the percentage of interventions in which the therapist challenged the client’s
perspective was low but stable over all sessions. Based on this, we became interested in
understanding how change emerged in the context of this kind of therapeutic collaborative
pattern. We followed two specific questions: What kind of therapist interventions pre-
ceded client’s innovations?; and, how did the therapist respond to client’s innovations?
Overall, 20% of the therapeutic exchanges, i.e. sequences of therapist’s intervention and
client’s response, were identified as operating in the potential level of the TZPD. Thus
Mary validated the therapist’s interventions of supporting innovation or challenging,
indicating either a safety or tolerable risk experience, depending on the level of elabora-
tion of her response. In addition, she often responds to supporting problem intervention by
minimally validating it and immediately elaborating innovation, indicating a tolerable risk
experience. For the following analysis we used only these kinds of therapeutic exchanges.
Therapist’s interventions preceding client’s innovations

The Challenging-tolerable risk therapeutic exchange was, on average, the less frequent
throughout the process (Figure 4). However, Challenging – safety was one of the most
prevalent therapeutic exchanges, indicating that in 32% of these interactions the client
accepted the therapist’s CH, but did not elaborate on it. Thus the client gave the therapist
indication of being empathically and accurately understood in her inner readiness toward
growth. Curiously, Supporting problem – tolerable risk is the second most prevalent
therapeutic exchange (28%), which indicates that the client moved beyond the level
proposed by the therapist’s intervention. Lastly, SI preceded 35% of client’s innovations
of which 22% corresponded to safety experiences and 13% corresponded to tolerable risk
experiences.
60 Supporting
problem-Tolerable
50 risk
Support innovation-
40 Safety
Index
30 Support innovation-
Tolerable risk
20
Challenge-Safety
10
0
Challenge-Tolerable
1 2 3 4 5 7 8 9 10 11 12 13 14 15 16
risk
Sessions
Figure 4. Percentage of therapist’s interventions preceding client’s innovation.

The following vignettes illustrate the two most prevalent therapeutic exchanges:
Challenging – safety and Supporting problem – tolerable risk.
Vignette 2 (session1): challenge – safety
Cl: if I’m alone that’s fine, but if I’m not like I have to go and ah – open my room and bite
the pillow or something you know (laugh).
T: so a lot of work goes also to make yourself stop crying. (Challenge, by using
interpretation)
Cl: yeah, no, it doesn’t happen! all the time but it happens more then I like it to in the past
little while. (sniffle). (Safety: giving information on innovation)
Vignette 3 (session 8) supporting problem – tolerable risk
Cl: yeah, yes, so it’s defeating, it’s a kind of circle you know
T: if it’s there you feel bad, if it comes out you feel bad and trying to keep it! down is hard. So
you’re really, you’re really stuck. you’re really as you say going in circles but, but really
hurting and it’s very painful. (Supporting problem: reflection)
Cl: (sniffle) (clear throat) so – it seems to be well that’s the reason why I’m here. – so I
thought I would try something – to talk to somebody because I don’t want it to be
such a big part of my life (...), I want to get out of it. (Tolerable risk: extend on
innovation)
Therapist’s responses to client’s innovations

Figure 5 shows that following the client’s responses indicating tolerable risk experiences,
the therapist privileged the supporting innovation’s intervention. These findings suggest
that the therapist preferred to remain close to the client’s innovative experiences, support-
ing them instead of challenging them more. Vignette 4 illustrates this therapeutic
exchange.
100
90
80
70
Tolerable risk-Supporting
60
problem
Index
50
40 Tolerable risk-Supporting
30 innovation
20 Tolerable risk-Challenge
10
0
1 2 3 4 5 7 8 9 10 11 12 13 14 15 16
Sessions
Figure 5. Percentage of therapist’s interventions succeeding client’s Tolerable risk.

120
100
80 Safety-Supporting
Index
problem
60
Safety-Supporting
40 innovation
20 Safety-Challenge
0
1 2 3 4 5 7 8 9 10 11 12 13 14 15 16
Sessions
Figure 6. Percentage of therapist’s interventions succeeding client’s safety (innovation).

Vignette 4 (session 10) tolerable risk – supporting innovation
Cl: Um, okay, when I first came in, um, I was, practically in tears over anything every day
(laugh) (T: right right) um (clears throat) I find that that has considerably, quite considerably
gone that idea of, really squishing it down (laugh) um – – I’m um, ah not, having fits as
much, like where I’m really, way up or, or the anger is like really, I haven’t had one of those
in, in quite a while. (Tolerable risk: extend on innovation)
T: So you feel like things are more stable? (Supporting innovation: specifies information)
Figure 6 shows that, when following the client’s responses that indicated a Safety
experience (on innovation), the therapist privileged the supporting problem’s intervention.
These findings suggest that most of the time the therapist preferred to return to the
problem exploration instead of remaining with the innovation. However she balanced
this option with interventions focused on innovation. Vignette 5 illustrates this therapeutic
exchange.
Vignette 5 (session 8) safety – supporting problem
Cl: yeah. And I think if I get something like that I won’t; because I’ve got something for me
the demands that are made by the family aren’t going to be such a big deal. (Safety: giving
information on innovation)
T: mm-hm. So if you get something for you +you might not feel as bad about the other
demands. And maybe you might be, maybe more – – I don’t know quite what the word is but
sounds like kind of more receptive to them a bit? And it’s the fact that you don’t have that for
you. (Supporting problem: reflection
Discussion
The findings of this case study highlight the collaborative nature of the therapeutic
interactions throughout the therapy process in a good outcome case. Indeed the dyad
worked most of time within the client’s TZPD, which means that the client validated most
of the therapist’s interventions. In terms of the TCCS, the client’s validation responses
mean that she felt understood in her internal experience, whether the therapist supported
or challenged her perspective. These client’s responses also suggest that the therapist was
able to be sensitive, moment-to-moment, to the client’s needs and also to her readiness to
change. Moreover it seems that the therapist rarely risked pushing the client beyond her
potential level of development as indicated by the lower percentage of invalidated
challenging interventions over all sessions. Also, when the client invalidated the rare in-
depth therapist’s reflections (challenge marker in TCCS), the therapist was sensitive to her
mistake and immediately returned to more supportive actions. This pattern of therapeutic
interaction underlines the importance of the therapist’s sensitivity to the client’s experien-
cing and the empathic nature of the therapist’s interventions in the context of a successful
person-centered therapeutic process. The empathic nature of the therapist’s attitude is a
crucial condition for further client change postulated by Rogers (1951) and person-
centered therapists. Although empathy is a complex and higher order construct (Bohart,
Elliott, Greenberg, & Watson, 2002), following Rogers’ later descriptions of empathy
person-centered therapists emphasizes the therapist’s ability to understand the client’s
frame of reference, “being sensitive, moment to moment to the changing felt meanings
which flow in this other person, to the fear or rage or tenderness or confusion or whatever,
that he/she is experiencing” (Rogers, 1975, p. 3). This therapist ability was considered by
E. Ribeiro et al. (2013) as an inherent condition to the collaborative therapist’s interven-
tions, since it facilitates the establishment of therapeutic work within the TZPD. In this
study, most of the time, the therapist supported the client’s perspective, making use of
meaning or feeling reflections. However, she also challenged the client’s perspective by
using a deep reflection beyond the level of the client’s immediate awareness, which
Mearns and Thorne (1999) called Empathy level 3 and which is coded as interpretation
while using the TCCS. As Bohart et al. (2002) pointed out, while manifesting an empathic
attitude, the therapist makes use of different kinds of interventions, such as questions,
reflections or even interpretations. In this clinical case, different specific therapist actions
led the therapist to join the client not only in the understanding of her own perspective but
also helping to deepen and broaden out some aspects of it, of which the client was not
aware, thus promoting change.
Regarding the client, the safety experience was most prevalent, either when the
therapist supported or challenged the client’s perspective. Thus the client validated the
supporting problem or supporting innovation interventions by accepting and giving
information from her own perspective and in line with the therapist’s reflections. She
also validated challenging interventions by accepting and giving some information on the
perspective proposed by therapist’s interpretations. However, this type of therapist inter-
vention was the most invalidated by the client, indicating her active agency in commu-
nicating and protecting herself from an intolerable risk experience. In accordance with
Bohart and Tallman (2010, as cited by Hoener, Stiles, Luka, & Gordon, 2012) we argue
that the client was “capable of self-healing and of creatively using psychotherapy in [her]
own therapeutic best interests” (p. 66), namely by feeling safe in her process of change.
Indeed, despite the importance of empathic therapist interventions in an effective ther-
apeutic collaboration, the findings also shed light on the client’s healing power. Therefore,
after some of the therapist’s supporting problem interventions, the client went forward
manifesting a readiness to change and a tendency for growth. This kind of client action
facilitated the therapeutic collaboration since the majority of those client responses were
followed by the therapist supporting innovation. As such we would say that the client
proactively created the opportunity for her own change instead of just reacting to the
therapist’s facilitation of change. Having in mind the theoretical basis of PCT, this was an
expected result since this type of therapy assumes that the client is an active agent of her
therapy and process of change (e.g. Bozarth, 2012; Hoener et al., 2012; Moon & Rice,
2012) Nevertheless, our findings also shed light on the therapist’s responsiveness to the
moment-to-moment client experience and the growth in her readiness for change. When
the client risked moving toward innovation, the therapist supported or challenged her
perspective even more. However when the client only accepted her proposals to work on
innovation, instead of elaborating them, the therapist became more cautious in her
interventions, thus balancing the focus of her interventions between client growth and
client vulnerability. Therefore we argue that the balance in therapist interventions was
enhanced by her non-directive attitude nourished by her sense of therapeutic freedom and
trust in the client’s self determination and active agency. A basic assumption of the
therapeutic collaboration-change model is that, in order to move towards change, the
clients need to feel safe and confident of being able to risk and open themselves to the
unknown, but as well as being understood in their experience, they also need to be
challenged to take risks (E. Ribeiro et al., 2013). The first idea of this theoretical
assumption emphasizes the therapist’s focus on the client’s frame of reference and her
resources, thus being in convergence with Rogers’ theory and empirical research on PCT
(e.g. Whitehorn & Betz, 1954, cited in Bozarth, Zimring, & Tausch, 2002, p. 152). In our
view, this case study emphasizes the therapist’s responsibility to work together with the
client in both directions. However, in both conditions, it primarily highlights how the
therapist stays close to the client’s experience (vulnerability or self-determination and
growth) and acknowledges her indications of being understood.
Conclusion and limitations

This case study supports the effectiveness of the therapist’s intentional non-directive
attitude (Moon & Rice, 2012), as it illustrates the way that she followed the client in
her own therapeutic journey. As well as this coherence with the PCT approach, the
therapeutic collaboration pattern that emerged in this case study emphasized a specific
balance on therapeutic interaction in which the client assumed a crucial role. However we
do not mean that the therapist was unimportant. In fact, the therapist’s willingness to
follow her client, being responsive to her needs or readiness for change was a critical
component of this balance.
Since this is the first analysis of a PCT clinical case with the TCCS, these results
should be consolidated by the analysis of PCT poor outcome and dropout cases and of
other kinds of therapeutic approaches as well.
Note
1. The concept of innovation was coined by Gonçalves et al. (2009) in their Innovative Moments
Model of narrative change. A. P. Ribeiro et al. (2013) were inspired by this concept to identify
the client’s potential level of change.
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Die Entwicklung therapeutischer Zusammenarbeit in einer

*Corresponding author. Email: eugenia@psi.uminho.pt

El desarrollo de la colaboración terapéutica en un caso de buenos

consultante se analizan momento a momento. Dos jueces independientes y entre-

Le développement de la collaboration thérapeutique dans un cas de

O Desenvolvimento da Colaboração Terapêutica num caso de sucesso de

terapêutica de desenvolvimento proximal da cliente (ZDPT), definida como a

Therapeutic collaboration-change model: therapeutic zone of proximal development

Therapeutic collaboration as a balance within the therapeutic zone of proximal

Person-centered therapy: which balance in the therapeutic collaboration?

The present study

Therapeutic Collaboration Coding System (TCCS)

Table 1. Therapist intervention coding subcategories.

Supporting subcategories Definitions

Reflecting The therapist reflects the content, meaning or feeling present in

and/or linked to contents that the client doesn’t reported or

Challenging subcategories Definitions

Table 2. Client response coding subcategories.

Validation subcategories Definitions

Confirming The client agrees with the therapist’s intervention, but

Invalidation subcategories Definition

judges agreed that Mary’s manifestations of incongruence or vulnerability included (1)

Figure 2. Percentage of category of therapist’s interventions throughout the therapy process.

Vignette 1(session1): supporting problem – safety

The way change emerged throughout the therapy process

Therapist’s interventions preceding client’s innovations

Figure 4. Percentage of therapist’s interventions preceding client’s innovation.

Vignette 2 (session1): challenge – safety

Vignette 3 (session 8) supporting problem – tolerable risk

Therapist’s responses to client’s innovations

Figure 5. Percentage of therapist’s interventions succeeding client’s Tolerable risk.

Figure 6. Percentage of therapist’s interventions succeeding client’s safety (innovation).

Vignette 4 (session 10) tolerable risk – supporting innovation

Vignette 5 (session 8) safety – supporting problem

Conclusion and limitations

practice (pp. 147–188). Washington, DC: American Psychological Association. doi:

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