Experiences of Crying in Psychotherapy: The Relationship with Change, Alliance, and Attachment

Katz, M., Hilsenroth, M., Johnson, N., Budge, S., & Owen, J. (2024). “Window of opportunity”: Clients’
experiences of crying in psychotherapy and their relationship with change, the alliance, and attachment.
Professional Psychology: Research and Practice. Advance online publication. https://dx.doi.org/10.1037/
pro0000559

Key Points

• Clients’ positive emotional and cognitive experiences after crying in therapy were associated with greater reported improvement and stronger alliance.
• Insecurely attached clients tended to view crying as more intense but also potentially more meaningful.
• Positive crying experiences remained significantly related to improvement even after controlling for alliance and attachment.
• Clients who cried in therapy reported greater improvement compared to those who did not cry in therapy.
• Therapists are encouraged to slow down, explore, and process crying experiences with clients as they may provide a “window of opportunity” to deepen the alliance and promote therapeutic change.
• The study provides cross-cultural validation of previous findings on crying in therapy from Italian and Israeli samples in a U.S. context.
• While crying in therapy appears beneficial overall, its impact depends on contextual factors and how the experience is perceived by the client.

Rationale

Crying is a uniquely human emotional expression that occurs frequently in psychotherapy, estimated to happen in 15-30% of sessions (Blume-Marcovici et al., 2017; Bylsma et al., 2021).

Over 80% of clients report crying at least once during therapy (Genova et al., 2021; Katz et al., 2022). However, the phenomenon of client crying in therapy has received limited empirical attention until recently.

Previous research has begun to examine relationships between crying in therapy and treatment variables like therapeutic change, the working alliance, and client attachment styles.

Studies in Italy (Genova et al., 2021) and Israel (Katz et al., 2022) found associations between positive crying experiences and greater reported improvement and alliance. There is also evidence that attachment styles may influence how clients experience crying in therapy (Katz et al., 2022).

The present study aimed to replicate and extend these findings in a U.S. sample to assess cross-cultural relevance. It also expanded on previous work by examining the unique contribution of crying experiences to change after controlling for alliance and attachment.

This research provides an initial framework for understanding how crying experiences, change, alliance, and attachment are interrelated in the therapeutic context.

Method

Clients completed an online survey about crying experiences in therapy as well as measures assessing therapeutic change, working alliance, and attachment style.

The survey took approximately 20 minutes to complete.

Descriptive statistics, bivariate correlations, partial correlations, t-tests, and chi-square tests were conducted using SPSS Version 20.

Sample

124 clients currently in psychotherapy participated.

The average age was 30.33 years (SD = 11.1). 69% identified as cisgender female, 22% as cisgender male, and 9% as other gender identities. 69% identified as non-Hispanic White, with other racial/ethnic groups represented in smaller percentages. 68% identified as heterosexual, with various other sexual orientations represented.

Measures

1. Crying in Therapy Survey (Genova et al., 2021; Hilsenroth, 2015; Katz et al., 2022): Assessed general crying tendencies, crying experiences in therapy, and thoughts/feelings about most recent crying episode in therapy.
2. Working Alliance Inventory-Short Form-Patient (Hatcher & Gillaspy, 2006): 12-item measure of therapeutic alliance.
3. Client Task Specific Change Measure-Revised (Watson et al., 1998): 16-item measure assessing client-reported therapeutic change.
4. Relationship Questionnaire (Bartholomew & Horowitz, 1991): Measure of adult attachment styles.

Results

1. Hypothesis 1: Client positive emotional and cognitive experiences reported post-crying in therapy will be related to reported positive change in therapy, while the opposite will occur for negative experiences after crying.
   
   Results: Supported. Feeling relaxed, in control, or happy after crying was positively associated with reported improvement. Feeling tense, depressed, or sad was negatively associated with improvement.
2. Hypothesis 2: Clients’ reporting that they felt their therapist reacted to their tears with support and compassion will be related to a better working alliance.
   
   Results: Supported. Perceiving the therapist as responding with compassion and support was positively associated with alliance.
3. Hypothesis 3: Other client emotional and cognitive post-crying 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.
   
   Results: Partially supported. Feeling more confident about reaching therapy goals after crying was related to stronger alliance. However, feeling crying was a moment of vulnerability was not significantly related to alliance.
4. Hypothesis 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.
   
   Results: Supported. Less securely attached clients reported feeling more uncomfortable with tears but also more likely to believe the therapist understood them better after crying.

Additional findings:

• Clients who cried in therapy reported greater improvement compared to those who did not cry in therapy.
• Most relationships between crying experiences and change remained significant after controlling for alliance and attachment.
• Insecurely attached clients tended to feel more uncomfortable with crying but also found it potentially more meaningful.

Insight

This study provides robust evidence for a direct relationship between how clients experience crying in therapy and therapeutic change, even when controlling for alliance and attachment security.

The findings suggest that crying in therapy can be a powerful catalyst for change when experienced positively by the client.

The results extend previous research by demonstrating that the relationship between crying experiences and change is not fully mediated by the alliance or attachment style. This indicates that crying itself may have unique therapeutic value beyond its impact on the therapeutic relationship.

The study also highlights the complex role of attachment in crying experiences. While insecurely attached clients found crying more uncomfortable, they also reported it as potentially more meaningful in terms of feeling understood by the therapist.

This suggests that crying episodes may be particularly impactful for insecurely attached clients, despite initial discomfort.

The gender differences found in crying tendencies (with women more likely to cry in therapy than men) warrant further investigation. Future research could explore how gender roles and socialization impact crying in therapy and its therapeutic effects.

Cross-cultural comparisons of crying in therapy remain an important area for future study. While this U.S. sample largely replicated findings from Italian and Israeli samples, nuanced cultural differences may exist in how crying is experienced and interpreted in therapy.

Strengths

• Replication and extension of previous international studies in a U.S. sample, providing cross-cultural validation.
• Examination of unique contributions of crying experiences to change by controlling for alliance and attachment.
• Use of validated measures for assessing change, alliance, and attachment.
• Inclusion of both emotional and cognitive aspects of crying experiences.
• Analysis of differences between clients who did and did not report crying in therapy.

Limitations

• Correlational design limits causal inferences.
• Retrospective self-report data may be subject to recall bias.
• Lack of information about specific therapeutic approaches used by clinicians.
• Sample demographics limit generalizability (predominantly white, female, heterosexual).
• Single time-point measurement does not capture changes in crying experiences over the course of therapy.

Implications

The results suggest that therapists should conceptualize client crying as a sensitive relational moment with potential for both positive and negative consequences. When clients cry, therapists are encouraged to:

1. Slow down and create space to explore the crying experience.
2. Respond with compassion and support.
3. Help clients express and explore the feelings tied to their tears.
4. Process what it was like for the client to share tears in the therapeutic space.
5. Revisit crying episodes in subsequent sessions to allow for reflection.

For insecurely attached clients, crying may be particularly uncomfortable but also uniquely valuable. Therapists should be attuned to attachment styles and provide extra support and processing around crying experiences for these clients.

The gender differences in crying tendencies highlight the need for therapists to be aware of potential societal and cultural factors influencing crying in therapy. Male clients or those from cultures where emotional expression is less encouraged may need additional support to feel comfortable crying in sessions.

Overall, the study supports the idea that crying in therapy can be a “window of opportunity” for deepening the therapeutic process and promoting change.

By skillfully navigating these moments, therapists can leverage the transformative potential of emotional expression in therapy.

References

Primary reference

Katz, M., Hilsenroth, M., Johnson, N., Budge, S., & Owen, J. (2024). “Window of opportunity”: Clients’
experiences of crying in psychotherapy and their relationship with change, the alliance, and attachment.
Professional Psychology: Research and Practice. Advance online publication. https://dx.doi.org/10.1037/
pro0000559

Other references

Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226-244.

Blume-Marcovici, A. C., Stolberg, R. A., Khademi, M., Mackie, A., & ‘t Lam, C. (2017). Tracking our tears: Research on therapist crying in therapy. In A. C. Blume-Marcovici (Ed.), When therapists cry: Reflections on therapists’ tears in therapy (pp. 23-39). Routledge.

Bylsma, L. M., Gračanin, A., & Vingerhoets, A. J. J. M. (2021). A clinical practice review of crying research. Psychotherapy, 58(1), 133-149.

Genova, F., Zingaretti, P., Gazzillo, F., Tanzilli, A., Lingiardi, V., Katz, M., & Hilsenroth, M. (2021). Patients’ crying experiences in psychotherapy and relationship with working alliance, therapeutic change and attachment styles. Psychotherapy, 58(1), 160-171.

Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short version of the Working Alliance Inventory. Psychotherapy Research, 16(1), 12-25.

Katz, M., Ziv-Beiman, S., Rokah, N., & Hilsenroth, M. (2022). Crying in psychotherapy among Israeli patients and its relation to the working alliance, therapeutic change and attachment style. Counselling & Psychotherapy Research, 22(2), 439-457.

Watson, J. C., Greenberg, L. S., Rice, L. N., & Gordon, L. (1998). Client task specific change measure-revised [Unpublished manual]. University of Toronto, Ontario Institute for Studies in Education, Department of Adult Education and Counselling Psychology.

Keep Learning

1. How might cultural differences influence the experience and interpretation of crying in therapy? What factors should we consider when comparing crying behaviors across cultures?
2. What ethical considerations arise when encouraging or exploring crying in therapy? How can therapists navigate the fine line between promoting emotional expression and potentially manipulating clients’ emotions?
3. How might the power dynamics inherent in the therapeutic relationship impact how clients experience crying in sessions? How can therapists address this?
4. Given the gender differences found in crying tendencies, how might societal expectations around emotional expression influence the therapeutic process for different genders? How can therapists address these potential biases?
5. How might different therapeutic modalities (e.g., cognitive-behavioral, psychodynamic, humanistic) approach and interpret client crying? What are the potential benefits and drawbacks of each approach?
6. How might the findings of this study apply to online or teletherapy settings, where crying may be experienced differently by both client and therapist?
7. How can therapists effectively process their own emotional reactions to client crying while maintaining professional boundaries?