Need Help With Discussion: Management Of Planned And Unplanned Termination

Need Help With Discussion: Management Of Planned And Unplanned Termination

References In APA:
Kirst-Ashman, K. K., & Hull, G. H., Jr. (2018). Understanding generalist practice (8th ed.). Stamford, CT: Cengage Learning.

  • Chapter 8, “Evaluation, Termination, and Follow-Up in Generalist Practice” (pp. 307–348)

Marmarosh, C. L., Thompson, B., Hill, C., Hollman, S., & Megivern, M. (2017). Therapists-in-training experiences of working with transfer clients: One relationship terminates and another begins. Psychotherapy, 54(1), 102–113. http://dx.doi.org.ezp.waldenulibrary.org/10.1037/pst0000095
 
Depending on the client and the length of treatment, saying goodbye can be hard for both of you.
While you generally anticipate that successful treatment will lead to the eventual termination of the client relationship, there are a variety of other reasons for why this relationship might come to an end. There might be a set number of sessions the client’s insurance will allow, or maybe the end of your internship is quickly approaching. Maybe termination results from the unexpected, like a new job or an illness, or the client leaves without notice. Regardless of the cause, you and your client must be prepared for the end of your working relationship.
In this Discussion, you reflect on the termination process, the potential feelings associated with ending a client relationship, and skills to address challenges related to termination.
Explain how you might evaluate client progress and determine when a client is ready to terminate services.

  • Describe a situation when a professional relationship may end before the client achieves their goals.
  • Describe one potential positive and one potential negative feeling that you, as the social worker, might feel regarding a planned termination and an unplanned termination.
  • Describe one potential positive and one potential negative feeling a client might feel regarding both a planned and an unplanned termination of a therapeutic relationship.Therapists-in-Training Experiences of Working With Transfer Clients: One Relationship Terminates and Another Begins
    Cheri L. Marmarosh and Barbara Thompson The George Washington University
    Clara Hill The University of Maryland
    Suzanne Hollman The Institute of the Psychological Sciences
    Monica Megivern The George Washington University
    Data from interviews with 12 graduate-level trainees about their experiences of working with clients who had been transferred to them from another therapist were analyzed using consensual qualitative research. Trainees reported a range of helpful and hindering aspects about the transfer experience related to the client (e.g., client had experienced a prior termination and transfer, client had severe character pathol- ogy), the prior therapist (e.g., prior therapist prepared client for transfer, prior therapists did not process their termination with client), themselves (e.g., participant was open to addressing grief, participant was fearful of rejection), supervision (e.g., the supervisor provided important feedback on dealing with loss, the supervisor failed to address the unique nature of transferring), training (e.g., there was not adequate readings on termination and transfer, there was no readings on transfers), and clinic practices (e.g., meeting with the prior therapist and current therapist facilitated process, having clients end treatment with debt hindered the development of the new relationship). Participants also provided recommendations for improving the transfer process. Implications of these findings for clinical practice, training, and research are addressed.
    Keywords: transfers, terminations, training clinics, psychotherapy, therapeutic relationship
    The literature on termination in psychotherapy often focuses on the ending of a therapy treatment, but it fails to address what happens when one treatment ends and the client is transferred. Transfers occur when therapists can no longer provide the necessary treatment, when therapists move or retire, or when the clinic provides training to therapists who rotate out of the setting. Clients are often transferred from one therapist to another when therapists-in-training leave the clinics at the end of their training year (Penn, 1990; Super, 1982; Wapner, Klein, Friedlander, & Andrasik, 1986). Given that this is the first clinical experience for many of these therapists, difficulties inevitably arise in understanding how to allow the transferred client to grieve the old relationship and establish a new relationship.
    In a review of the client perspectives on the transfer process, Keith (1966) developed the term “transfer syndrome” to denote the difficult emotions and behavioral changes experienced by clients who end treatment with one therapist and begin treatment with another. Re- searchers and clinicians described clients’ feelings of abandonment, grief, and loss (Clark, Cole, & Robertson, 2014), anger/rage toward the transferring and new therapist (Penn, 1990), and feelings of unworthiness (Penn, 1990). Attachment theory has been used to understand why clients with anxious attachments experience aban- donment after the ending with a therapist, whereas clients with avoidant attachments detach and resume therapy as if nothing hap- pened (Holmes, 2006).
    Clients are not alone in experiencing the transfer syndrome. Some therapists are able to tolerate clients’ experiences of termination and loss, whereas others who had prior personal losses struggle with termination process (Boyer & Hoffman, 1993) and probably with the transfer process. Unfortunately, we have minimal empirical informa- tion to guide us through this important ending and beginning. The purpose of the present study was thus to study the experiences of therapists-in-training with regard to their work with transfer clients who recently experienced the termination of a relationship.
    The Impact of Transfers on Clients: Empirical Findings
    Much of the transfer research has focused on how the transfer- ring of clients from one therapist to another can impact attrition (Tantam & Klerman, 1979), with some studies reporting a dropout rate as high as 69% after a transfer (Tantam & Klerman, 1979;
    Editor’s Note. Mark J. Hilsenroth served as the action editor for this article.—MJH
    Cheri L. Marmarosh, Professional Psychology, The George Washington University; Barbara Thompson, Graduate School of Education and Human Development, The George Washington University; Clara Hill, Counseling Psychology, The University of Maryland; Suzanne Hollman, Clinical Psychol- ogy, The Institute of the Psychological Sciences; Monica Megivern, Graduate School of Education and Human Development, The George Washington University.
    Correspondence concerning this article should be addressed to Cheri L. Marmarosh, Professional Psychology, The George Washington University, 1922 F Street, Suite 3, Washington, DC 20052. E-mail: cmarmarosh@ gmail.com
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    Psychotherapy © 2017 American Psychological Association 2017, Vol. 54, No. 1, 102–113 0033-3204/17/$12.00 http://dx.doi.org/10.1037/pst0000095
    102
    mailto:cmarmarosh@gmail.com
    mailto:cmarmarosh@gmail.com
    http://dx.doi.org/10.1037/pst0000095
    Wapner et al., 1986). These findings indicate that many clients do not survive a transfer, and it is critical that we try to understand more about what goes on during this process to train clinicians to help prevent premature termination.
    Two factors have been identified as relating to transfer success: (a) the length of time in treatment before the transfer, and (b) having had a prior transfer experience (Clark, Robertson, Keen, & Cole, 2011; Wapner et al., 1986). Those who have had a long relationship with a therapist before ending the relationship and transferring to a new therapist, or who had a past transfer experi- ence, were less likely to drop out after the transfer than their counterparts.
    In a qualitative study, Clark et al. (2014) interviewed 11 clients about their personal experiences of being transferred at some time during their treatment. Most clients indicated that they felt some anxiety, fear, sadness, and anger about the transfer. They noted that it was helpful when the new therapist and clinic were sup- portive of their reactions and helped them cope with their feelings. Successful transfer clients felt that their new therapists’ compe- tencies and effectiveness facilitated their ability to navigate their transfers. These clients were able to have a positive attitude and form a strong alliance with the new therapist.
    The Impact of Transfers on Therapists-in-Training: Empirical Findings
    Schen, Raymond, and Notman (2013) asked 23 psychiatric residents to complete a 20-item questionnaire about their experi- ences working with transfer patients in psychotherapy. They found that transferring residents felt guilty, sad, anxious, and even re- lieved to transfer their patients. In contrast, transferred-to residents felt badly about being compared with prior residents, felt over- whelmed when patients were grieving the loss of their prior clinicians, and feared transfer patients’ negative emotions about repeating an intake, rehashing the past, or starting over.
    The Schen et al. (2013) study is useful because it exposes some of the challenges of working with transfer clients. Not surprisingly, working with a transfer client can be very stressful for therapists- in-training who have limited experience exploring grief and toler- ating clients’ negative/ambivalent feelings toward them. Because novice therapists are often overwhelmed with their own anxieties about being evaluated and seeing clients for the first time (Hill, Sullivan, Knox, & Schlosser, 2007), they may not be the best candidates for taking on these cases without necessary training and supervision.
    Although the Schen et al. (2013) study opened the door to understanding the critical impact of transfers on trainees, it is limited because it is unclear how the researchers developed items for their questionnaire for assessing transfer attitudes, and no psychometric data were reported. To analyze the results, it appears that the authors qualitatively identified major themes by reviewing the responses to the questionnaire, but they did not report any method used to understand these data. In addition, given that the study involved beginning psychiatrists, we do not know if the results would generalize to psychologists and counselors-in- training who have more psychotherapy training.
    Purpose of the Current Study
    The primary purpose of the current study was to explore how therapists-in-training experienced their work with their first trans- fer clients. We were interested in the topic not only for practical reasons (i.e., how to make the transfer process smoother for therapists and clients) but also for theoretical reasons (i.e., what might account for different client and therapist reactions to the transfer process). We were most interested in what client and therapist characteristics influenced the transfer process, how the experience with transfer clients influenced the identity of begin- ning therapists, and how transfer clients were experienced differ- ently from nontransfer clients. In addition, we wondered about what recommendations therapists-in-training would have for su- pervisors and training clinics where terminations and transfers occur regularly.
    We chose to use a consensual qualitative research method (CQR; Hill, 2012; Hill et al., 2005; Hill, Thompson, & Williams, 1997) so that we could learn more in-depth about the topic to help us develop better clinical strategies and design better empirical studies to answer the emerging theoretical questions. CQR is a rigorous approach that allows for an in-depth examination of inner experiences.
    Method
    Data Set and Description of Clinics and Client Population Served
    Participants were therapist trainees from two university-based clinics, both of which served the same urban population. One of the clinics was housed in the Professional Psychology Program (PP clinic) and one was in the School of Education (SE clinic) at the same private Mid-Atlantic U.S. University. Both training clin- ics provided sliding scale, low fee, time-unlimited psychotherapy to diverse clients. When looking at the demographics of the trans- fer clients in this study, four clients were reported by the partici- pants as being African American, six clients were reported as being Caucasian, and two were not known. The racial background was similar between the two clinics. Specifically, in the PP clinic, two of the clients were African American, three were Caucasian, and one did not identify race. In the SE clinic, two clients were African American, three were Caucasian, and one did not identify race. There were more males seen in the SE clinic compared with the PP clinic. Seven clients were male (two in the PP clinic and five in the SE clinic) and five were female (four in the PP clinic and one in the SE clinic).
    Similarly, the training clinics both serve a diverse range of clients with diverse presenting concerns. Formal diagnoses of clients were not assessed given the focus was on the trainee’s experience of the transfer, and the clinics did not require formal assessment of diagnoses. We determined the range of client func- tioning from the descriptions of the clients made by the partici- pants. According to the participants, clients ranged from unem- ployed individuals with serious chronic mental illness (six clients with personality disorders, severe depression, and chronic disabil- ity) to higher functioning clients (six clients with relationship issues, depression, anxiety, and/or family difficulties). In the PP clinic, three were described as higher functioning, with depression
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    103THERAPIST EXPERIENCES OF TRANSFER CLIENTS
    and relationship issues being the presenting concerns. Three were described as lower functioning, with personality disorder and trauma being the presenting issues. In the SE clinic, two were described as being higher functioning, whereas four were de- scribed as having personality disorders, addictions, depression, and trauma. Three of the clients had had one prior transfer, three had had two prior transfers, with the remaining six clients have had from three to eight prior transfers. We went back to the case material to determine the outcome of the transfer cases and found that six clients stayed in the treatment the entire time (about one year) and were transferred again, one was still in treatment with the same therapist at the time of the interview, two were referred out of the clinic at the end of the treatment, one moved out of the area (mutual termination), and one was not known. Only one was identified as prematurely dropping out of the therapy by the participant after approximately seven months of treatment.
    Therapists-in-training in both clinics typically worked in their respective clinics for one year, and clients were offered transfers when trainees left both clinics. In regard to the process of trans- ferring clients, there were some similarities and differences be- tween the two clinics. In the PP clinic, staff assigned the transfer case to a new therapist. The new therapist was required to meet with his or her supervisor to plan for the initial session and determine what information the therapist should review before meeting with the client. A new intake was not always required as therapists relied on documentation in the file. None of the partic- ipants in the PP clinic had a transfer meeting with the client, prior therapist, and themselves.
    In the SE clinic, the prior therapist and his or her supervisor made the decision about whether to terminate, transfer, or refer out the client. Whenever possible, a brief transfer meeting was rec- ommended between the client, transferring therapist, and new therapist before the end of treatment with the transferring therapist. The new therapist was required to conduct an intake with the transferring client. In the SE clinic, four of the participants met with the client, prior therapist, and client, but only one was described as a lengthy process. The other three were described as brief introductions and focused on scheduling. Regardless of the differences in the clinics, 10 of the 12 therapists said they met with the prior therapist before seeing the client.
    Trainee Participants
    Participants included six doctoral level students from the PP Clinic in their 2nd to 3rd year of doctoral training and six masters- level students in the SE Clinic in their 2nd year of graduate training. Of the 12 participants, six were Caucasian (three from PP clinic and three from the SE clinic), two Asian American (one from the PP clinic and one from the SE clinic), one Latin American (from the PP clinic), one Arab American (from the PP clinic), and two African American (from the SE clinic); 10 were women and two were men (both from the SE clinic). The average age was 29.77 (SD � 7.51). Using 5-point scales where 1 � strongly disagree, 5 � strongly agree, participants rated themselves as an average of 3.62 (SD � 1.34) on psychodynamic, 3.38 (SD � 1.18) on humanistic, and 3.23 (SD � 1.24) on cognitive–behavioral orientations. One-way ANOVAS were used to determine if there were differences among the three orientations endorsed between the two clinics, and the results revealed that therapists in the PP
    and SE clinics were not endorsing significantly different reliance on humanistic or dynamic theory/technique when working with their clients; however, participants in the SE clinic were using significantly more CBT (M � 4.50, SD � .55) compared with participants in the PP clinic (M � 2.33, SD � 1.21), F(1, 10) � 15.93, p � .01).
    When asked about the number of clients seen in the clinic at the time of participation, participants said they had treated an average of 4.67 (SD � 1.87) clients, with a minimum of two clients and maximum of nine clients. In the PP clinic, three participants had worked with at least two transfers, and three participants had worked with at least three transfers. At the SE clinic, three had worked with at least two transfers, two had three transfers, and one had four transfers. Combined, they reported an average of 2.58 (SD � .67) transfer clients with a minimum of 2 and a maximum of 4 transfer clients each.
    The primary research team, who served as both interviewers and judges, consisted of four White female licensed practitioners (two Ph.D., one Psy.D., and one Ed.D) who were all involved in both independent practice and academic positions at the same university (two in the PP, two in the SE Program). The auditor, a White female, was a psychology professor and director of a small de- partment clinic at another university. Two of the five, including the auditor, had extensive experience with CQR. Because all were involved in university clinics that had transfers, these judges and the auditor had biases and expectations regarding the difficulties of transfers from the perspectives of therapists, clients, and supervi- sors. In discussing their biases and expectations before data col- lection, the primary team all believed that transfer clients present unique challenges for therapists-in-training, that these challenges impact trainee development, and that trainees would benefit from more training in how to work with transfer clients. All also believed that, even though the transfer process can be difficult, transferring clients is preferable to shortening treatment when clients still need therapy given a bias toward long-term psychody- namic treatment.
    Measures
    Demographic form. The demographic form asked for partic- ipant age, sex, race/ethnicity, degree (MA, MFT, MS, MSW, PhD, PsyD, other), and theoretical orientation.
    Interview protocol. The primary research team worked to- gether to develop the interview protocol and then modified it following two pilot interviews, which were not used in the anal- ysis. The semistructured interview (see Appendix), which lasted 60 to 90 min, included questions about the participant’s general experiences with transfers, their experiences with a specific chal- lenging transfer client and what facilitated and hindered the trans- fer process, how their transfer experiences influenced their profes- sional identity, and recommendations for improving the transfer process.
    Procedure
    Selection of participants. Criteria for participation included graduate students who were in or had recently completed their first year of treating clients (at least 2nd year in both programs) and who had worked with and terminated with at least two transfer
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    104 MARMAROSH, THOMPSON, HILL, HOLLMAN, AND MEGIVERN
    clients. At least one of these two transfer clients had to have been in treatment for a minimum of three sessions, not including intake. When an announcement went out inviting students to participate, out of �35 students, we selected the first 16 students who agreed to participate (eight from each clinic). One interview was dropped due to the poor audio quality and the inability to code the re- sponses. Because we wanted an equal number of interviews across interviewers and clinics, three participants were not interviewed, leaving 12 participants in the study.
    Interview. If the therapist-in-training consented to participate, he or she was scheduled for an interview with a member of the research team from the other clinic. Participants were given the interview protocol prior to the scheduled interview so that they could prepare. Immediately before the interview, participants pro- vided informed consent and completed a demographic form. Each of the four interviewers conducted one 60 to 90 min individual audiotaped telephone interview with three participants. Interviews were transcribed verbatim (other than minimal encouragers, si- lences, or stutters); identifying information was deleted, and each participant was given a code number to protect confidentiality.
    Data analysis. There are three primary steps in CQR data analysis (Hill, 2012): domain coding, core ideas, and cross anal- ysis. In domain coding, each member of the primary research team individually read through five transcripts and identified topic areas in the data that become domains (e.g., facilitating client charac- teristics, hindering client characteristics). The primary team then reviews the created domain list by consensus and assigned seg- ments of the five interviews to these domains. At that point, the team split into two teams each with two people to do the domain coding for the remaining transcripts. The alternate team “audited” the other team’s work; differences were resolved by consensus.
    The next phase in the data analysis, constructing core ideas, involves taking the sections or units for each domain within a case or transcript and rewriting them to maintain the gist of the data but in a format that is more abstract and concise. As a very brief example, the statement from one of the participants, We have the capacity to talk to the previous counselor before the transfer process is completed, which is very helpful was transformed to Being able to talk to previous counselor was helpful. As in all other steps, the primary research team reached consensus on all of the core ideas before proceeding.
    The final data analysis step, the cross analysis, involves deriving themes for the core ideas in each domain across all the cases (see Table 1). So, for example, all of the core ideas from all cases related to the domain of Hindering Prior Therapist Characteristics were analyzed and the research team developed the categories of Hindering “Prior Therapist’s lack of professionalism,” “Prior Therapist personal qualities,” and “Prior Therapist’s lack of tech- nical skills.” These categories were also finalized based on con- sensus between members of the research team.
    The auditor reviewed each step of the data analysis process and provided comments and suggestions that were reviewed by the research team. Changes were made if consensually agreed upon by the primary team.
    Results
    Once the cross analysis for all domains was completed, we compared results for the two clinics. A difference between the
    participants’ responses in the two clinics of at least 30% was considered to be meaningful, following guidelines suggested by Ladany, Thompson, and Hill (2012). Only two categories met the criterion of a 30% difference. PP clinic participants more often than SE clinic participants recommended that the new therapists process the transfer fully with the client, even if the client was resistant (83% vs. 33%) and said that there should be a meeting between the client, transferring therapist, and new therapist (83% vs. 50%). Given the lack of other meaningful differences, the results between the two clinics were combined in the subsequent results.
    Following CQR guidelines (Hill, 2012), findings that emerged for 11 to 12 cases were labeled general, those that emerged for 7 to 10 cases were labeled typical, and those that emerged for two to six cases were labeled variant. Only the general and typical find- ings are discussed in the text, although all the findings are shown in Table 1. We use quotations from the cases to illustrate themes; ellipses (. . .) are used when words were deleted; phrases such as “you know” and redundancies were removed to allow for easier reading.
    Prior Therapist Characteristics That Influenced the Transfer Process
    Facilitating characteristics. Participants typically noted that the prior therapist’s professionalism, following the tasks and role requirements of a clinician in the clinic, helped the transfer to the new therapist. One participant said that the prior therapist was very prepared. She gave me a lot of good information about how she had worked with him and what she saw were the important things. Her files were very thorough.
    In addition, some of the prior therapist’s personal qualities typically facilitated the transfer process. For example, one prior therapist was described as having a nurturing way and cared a lot about clients . . . and wanted to see them improve . . . there was the current atmosphere (referring to prior therapist) of empathy, and awareness of how difficult the (transfer) process may be.
    Hindering characteristics. Participants typically described a lack of professionalism, not following the tasks and responsibili- ties as a trainee in the clinic, on the part of the transferring therapists as having hindered the transfer process. For example, one participant noted that the “client’s previous therapist did not bill her [client] regularly and my new client had a very large balance.” In this example, the participant felt like the she was the mean therapist who was going to hold the client to the clinic policies, which set us off on the wrong footing.
    Participants also typically noted that some problematic personal qualities and a lack of technical skills of the prior therapist hin- dered the transfer process. Encompassing both categories, one participant said that the previous therapist was pretty reserved or passive and told me that he had difficulty talking about termination with the client.
    Characteristics of Current Therapist That Influenced the Transfer Process
    Facilitating characteristics. Participants generally felt that some of their personal qualities had facilitated the transfer process. For example, some participants described their past life experi-
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    105THERAPIST EXPERIENCES OF TRANSFER CLIENTS
    Table 1 Categories and Subcategories Within Domains for Characteristics That Influenced the Transfer Process
    Domain/Category/Subcategory Frequency
    Prior therapist characteristics Facilitating characteristics
    Prior Therapists’ professional qualities T (9) Prior Therapists’ personal qualities T (9) Prior Therapists’ technical skills V (6)
    Hindering characteristics Prior Therapist’s lack of professionalism T (8) Prior Therapist’s personal qualities T (7) Prior Therapist’s lack of technical skills T (7)
    Current therapist characteristics Facilitating characteristics
    Current Therapist’s personal qualities G (11) Current Therapist’s technical skills T (9)
    Hindering characteristics Current Therapist’s personal qualities G (12) Current Therapist’s lack of technical skills T (10)
    Transferred client characteristics Facilitating characteristics
    Client preferences for new therapist met T (7) Client prior transfer experience V (6) Client able to form a relationship V (3) Client commitment to therapy V (4)
    Hindering characteristics Client’s Psychopathology G (11) Client preference for new therapist were not met T (7) Client difficulty forming a relationship V (5) Client weary of being transferred V (4)
    Supervisor characteristics Facilitating characteristics
    Provided helpful guidance about how to work with transfer clients T (9) Supervisor was supportive V (6) Supervisor knowledge about case from prior therapy V (5)
    Hindering characteristics Failed to provide guidance about how to work with transfer clients T (7)
    Characteristics of training clinic Facilitating characteristics
    Clinic policies and procedures T (10) Institutional aspects of clinic T (10) Documentation requirements T (9)
    Hindering characteristics Little or no training about the transfer process provided G (12) Clinic policies and procedures T (10) Meeting with prior therapist was not helpful V (3) Timing of the transfers hindered the process V (6) Training needs not always best for clients T (9)
    Influence of transfer on therapist Seeing transfer clients increased participant self-confidence/self-efficacy T (9) Participant learned about important aspects of therapy/therapy process T (8) Seeing transfer clients increased participant self-doubt V (6)
    Influence of transfer on client Hindered client growth T (8) Facilitated client growth V (5)
    Differences between transfer and nontransfer clients Transfer and nontransfer clients are different in early phases of treatment G (11) Transfer and nontransfer clients were similar in some ways V (5)
    Recommendations Training clinic provide guidelines and structure the transfer process G (11)
    Clinic make it policy to have a meeting between old/new therapists and transferred client T (8) Streamline transfer process T (7)
    Clinic provide specific training about transfer process for therapists T (10) Transferred-to therapists should be sensitive to prior therapy in early interventions and logistics T (7) Transferring therapist prepare client for transfer process T (7) Provide ongoing support to new therapist and maintain oversight over the transfer process V (6) Assess transferring client’s needs and ability to tolerate transfer V (5)
    Note. N � 12, 6 in each of two clinics. General � 11 to 12 cases, Typical � 7 to 10 cases, Variant � 3 to 6 cases.
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    106 MARMAROSH, THOMPSON, HILL, HOLLMAN, AND MEGIVERN
    ences as helpful. Thus, one participant felt that his age and work as a pastor helped him feel very confident in my ability to communi- cate to others and to connect to others. Another participant felt that because of her age and having had children, the whole sense of knowing who I am and where my comfort zone is and how I would feel being in someone else’s shoes made the transfer process easier. Another participant had “patience” and a “laid back style,” which enabled her to “act as a container” for the transfer client who was distressed by the ending of the prior therapy.
    In addition, participants typically noted that some of their tech- nical skills enhanced the transfer process. One participant sensed that her ability to help the client “explore their previous relation- ship with their therapist . . . allowed them to process the ending better.” Another participant noted that having a good idea of a treatment plan, instead of just winging it as some of her colleagues did, helped with the transfer process. Other participants cited that being empathic and supportive was helpful in dealing with the client’s loss after the transfer.
    Hindering characteristics. Participants also generally indi- cated that some of their personal qualities (e.g., personal insecu- rities, feelings of anxiety, and having a negative attitude) made the transfer process more difficult. One participant stated,
    I just was pretty insecure about my ability to really do this [psycho- therapy with a transfer client] when I was sitting in the room with somebody that I know had a therapist that had years’ experience . . . I was very intimidated and I think for the first two sessions it was very hard for me to speak . . . my own natural insecurity was heightened in that particular setting.
    Participants also typically felt their lack of technical skills (e.g., lack of experience, not knowing how to process feelings about the prior therapist with the client) hindered the transfer process. One participant stated that because she was new to counseling, she “wasn’t very confrontational . . . transfer clients have been in therapy for a really long time in our clinic and need a lot more confrontation, so that was difficult to me.”
    Client Characteristics That Influenced the Transfer Process
    Facilitating characteristics. Participants typically indicated that meeting their clients’ preferences for a new therapist (i.e., therapist having the gender the client requested) facilitated the transfer. One participant said,
    I know he was relieved having a Caucasian woman as his new counselor. He professed to not work well with anyone of a minority status . . . he’s a very strong Catholic, and I think that having a transfer counselor who understands his religion was important.
    Hindering characteristics. Participants generally described how the clients’ defenses or psychopathology hindered the transfer process. One participant described,
    I do not think he ever attached to anyone because of a really profound fear. He would talk about things in a very abstract or the most nonspecific way possible. He couldn’t discuss our relationship in any way. Anytime I tried to direct him toward something that was hap- pening with displacement or something that was happening with us, he could not imagine it or even talk about it at all. He’d become very
    disorganized, and if I would even draw his attention to it he would lean toward saying that he wanted to terminate.
    Participants also typically suggested that unmet client prefer- ences (e.g., about the gender, race, or style of the new therapist) hindered the transfer process. For example, one male participant said that, “The client . . . did not want to work with a man . . . and that made it very challenging.”
    Impact of the Supervisor on Transfer
    Participants felt that supervisors both contributed to their work with transfer clients and also failed to always help them navigate the transfer process. In essence, participants felt that there were benefits to supervision and also areas that needed more attention when they were working with transfer clients.
    Facilitating characteristics. Participants typically said that the guidance provided by supervisors regarding the transfer pro- cess was helpful. Specifically, participants noted the supervisors gave helpful information about what to do or say when working with a transfer client. One participant’s supervisor reviewed the client demographic information with me, and when I asked her, she would offer her opinion on working with a client with that background, ‘Here’s what I would do, here’s what I have done in my practice’.
    Hindering characteristics. Participants also typically indi- cated that supervisors failed to provide adequate support for and practical guidance about dealing with transfer clients. One partic- ipant said she would have liked a little bit more support from him [supervisor]. I would have liked to better understand what to talk about the first couple of sessions. How do you bring the history in without repeating things? How do you start a new relationship with this person?
    Characteristics of the Training Clinic
    Facilitating characteristics. Typically, participants thought that a number of the training clinic policies or aspects of the clinic facilitated the transfer process. Specifically, they mentioned that the clinic policy of meeting with the transfer client’s prior therapist was helpful. One participant noted that “we have the capacity to talk to the previous counselor before the transfer process is com- pleted, which is very helpful.” In addition, participants typically noted that several aspects of the training, such as having access to documentation from prior therapies and the continuity of proce- dures or institutional aspects of the clinic, facilitated the transfer.
    Hindering characteristics. Participants generally felt a lack of specific training about transfer clients left them unprepared to do things such as integrate known history into the process or exploring the client’s loss of the prior therapist. One participant said, There wasn’t a lot of preparation to understand the transfer process . . . no one really prepped me how they may struggle with this loss and how it really is like grief work.
    Participants also typically noted that there were certain clinic policies such as the timing of the transfers that seemed to hinder the transfer process. One participant said,
    Our clinic doesn’t do a very good job assessing clients at the end of each treatment to see if they should continue therapy with our clinic. I think that a lot of our clients in the clinic have a tendency to get
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    107THERAPIST EXPERIENCES OF TRANSFER CLIENTS
    overlooked. We have patients who have been in our clinic for about 8 years and could really benefit from a different mode of treatment. Often it’s left up only to the supervisors, which is important because they know the case, but each year the clients get a new supervisor and therapist so they get lost in the mix sometimes. So I think it would be more helpful if the clinic were able to assess each case to the extent that they can and instead of making it a given that people continue, ask whether it’s appropriate to continue.
    Influence of Transfer on Therapist Participants
    Typically, transfer experiences influenced therapists’ self- perceptions, particularly helping them gain confidence and self- efficacy. One therapist noted that the experience helped her and that she could handle any situation now. Another therapist noted,
    I think it really urged me to be confident in how I wanted to find myself professionally based on these anxieties that were coming from the inner dialogue of having a transfer client. It helped me to really listen to myself and to what I feel comfortable with and to allow that to create my identity. I do not think it’s 100% there quite yet it pushed me toward that.
    Participants also typically reported that they had gained insights about important aspects of therapy or the therapy process (e.g., gained insight about the limitations of counseling, importance of boundaries, the need for flexibility, openness, patience, not making assumptions, and the need to process termination). One participant said,
    I learned how important it is to really try to talk about the termination no matter how difficult it is. Even if they are defended and they say they feel fine, you really have to prepare them for how difficult it really will be. You really have to state that this transition will not be easy, and you have to let them know. You really have to prepare them for how uncomfortable it may feel when they start with someone new. That’s really all you can do, really probing it and really discussing the termination no matter how much they may seem to veer off from it.
    Influence of Transfer on the Transfer Client
    Participants typically believed that transfers were hindering for the clients, in that it was challenging, stressful, and reinforced clients’ avoidance of deeper issues. One participant described how dealing the loss was challenging,
    I just had to be really, really patient, and mourn with them. I saw it as kind of a mourning process, that termination and that relationship and the loss, to some degree, so I would talk to them frequently about that, especially when they would express certain feelings of ambivalence or loss, we’d talk about the last counselor and stuff like that so they knew that I understood that it was difficult talking to me as a new person right in the middle of their treatment.
    Difference Between Transfer and Nontransfer Clients
    Participants generally reported differences in the early phases of treatment in their experiences working with transfer and nontrans- fer clients. For example,
    With nontransfer clients, it has been very different because kind of right at the beginning I am the one that is setting the frame around the treatment with them, it seems like they have more of a fresh start. They have not had any previous experiences in the building or
    working with somebody else. I am the one that gets to gather a lot of the personal history. So rather than having personal history and experiences filtered through somebody else, I bring it in and I kind of think about it. When you get a transfer client, everything has been affected by the previous therapist or their experiences there. There is a very different experience.
    Recommendations for Transfers in Training Clinics
    Generally, participants recommended that training clinics pro- vide more guidelines and structure about the transfer process. They wanted specific guidelines about what should happen during the transfer process including what to discuss and how to discuss it. One person said, Having a more standardized way of the previous therapist presenting the material to the new therapist, being taught what the appropriate ways are to provide information, and how much should be presented, and in what manner so that the per- sonal opinion doesn’t get involved with the overall history.
    Another participant recommended that the training clinic pro- vide “a sample script . . . Here’s an interesting way to start an intake with a transfer client to help them feel like they won’t have to start from scratch and help them get more comfortable.”
    Within the general category of recommending more specific guidance, several typical categories emerged. One area that par- ticipants typically recommended was making the meeting between the prior therapist, client, and new therapist more standardized. For example, one participant said,
    Having set procedures would help facilitate the process both for clients and for therapists. I think that for a lot of cases it would be a positive thing to meet with the previous therapist and the new thera- pist, to help ease that transition. I feel like patients coming in, especially if they’ve been working with someone for a while, they come in and it can be very confusing for the therapist and the client . . . not knowing what the therapist looks like, and it being all so unfamiliar. . . . When I transferred one of my patients to the next therapist, I had them meet in the room with me. Because I felt like it would ease the transition so I think that would be a good procedure to have.
    Participants also typically felt that the transfer process could be streamlined to facilitate the process. Some ideas were to lessen the gap between old and new therapists, provide more information about how to contact the transferring client, and make the paper- work logistics simpler.
    Not surprisingly, participants typically wanted more didactic training and specific readings geared toward working with the transfer clients. For example, one participant requested some ses- sion in class or with supervisor about the types of clients that transfer and the cases where someone’s in counseling for years and you get them. The qualities of those types of clients and what to look out for, and how they are different vs. taking on a new client.
    In addition to recommendations about the clinic or training program, participants typically had recommendations for therapists transferring the clients. They suggested that transferring therapists process the transfer fully (e.g., share the value of having different therapist or approach, work with their clients’ feelings about the transfer), prepare clients for the transfer process (e.g., expectations about paperwork, procedures such as new intakes), and schedule
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    108 MARMAROSH, THOMPSON, HILL, HOLLMAN, AND MEGIVERN
    enough time to prepare for the termination with clients. One participant specifically recommended,
    I think taking time, in advance of the transfer, to process their (clients’) feelings about it (terminating) and any issues that come up for them about termination and transfer . . . to help clients by bringing it (transfer) up sooner than later, cause that’s establishing a plan for transfer and making sure they agree and understand, outlining goals or things that they want to do before their last session before the transfer.
    Another participant remarked on how the lack of planning in advance on the part of the transferring therapist inhibited her from collaborating with the transfer therapist because there was not enough time. She said, What often happens, especially with the two transfers that I just recently got was that it (the transfer) happened a week before the person (transferring therapist) was leaving.
    Typically, participants had a variety of recommendations for transferred-to therapists about to see transfer clients. They sug- gested that new therapists should be sensitive to the client’s prior therapy experiences and try to help them feel comfortable with the transfer process. One participant recommended that new thera- pists, basically make sure that the gap between transfers is no more than a regular break and it keeps them on their regular schedule, or as close as it can be. Another participant noted that,
    I would have spent more time exploring their experiences with the previous therapists because they seemed to let that drop very quickly. They seemed uninterested in reflecting on that, but I think that ultimately discussing that loss could have been fruitful. I just think that reflecting upon that loss made me a little bit nervous about going there because I didn’t want to push them, so I was going to let them talk about what they wanted to talk about. It’s hard as a beginner to know how much time to give that previous therapy that just terminated, and I wish I would have stayed with that longer.
    Discussion
    Working with clients who have been transferred from another therapist seems to be difficult and challenging for many therapists- in-training, with many things facilitating and hindering the pro- cess. The information these therapists provided revealed their sensitivity about their role in the transfer process and the needs of their clients. Many of their observations can be used to facilitate changes in clinic policy and needed training for therapists with regards to how to help clients navigate transfers.
    Influence of Transferring Therapists
    The prior therapists were viewed as having facilitating personal characteristics, in that they were nurturing, mature, and had good documentation practices. In essence, most important personal characteristics of empathy, genuineness, and responsibility that facilitated the process of the transfer were the same ones that have been shown to facilitate psychotherapy treatment in general (Messer & Wampold, 2002). But there were also hindering per- sonal characteristics that interfered with the transfer, in terms of therapists being reserved, passive, having poor billing practices, or not having adequate skills and knowledge for processing the loss with their transfer clients. It was clear that many therapists would have benefitted from specific training to help them help their clients manage the transition.
    Influence of Transferred-to Therapists on Transfers
    The therapists-in-training in our study also all acknowledged their own role in the transfer process. Specifically, they thought that some of their personal qualities, feelings, or experiences facilitated the process whereas other personal qualities, feel- ings, and experiences hindered the transfer process. Adaptive emotional responses that facilitated the transition included a positive attitude toward the transfer process such as being patient during the initial phases of the transfer and accepting that, in the words of one participant, this is just something therapists have to battle through. In addition, participants viewed their own technical skills related to crisis management and dealing with strong affect, for example, client anger, as facilitating factors. These results are similar to those of Schen et al. (2013), who identified the ability to tolerate and deal with anger as a necessary skill when working with transfer clients. The thoughts and feelings that were viewed as hindrances included feeling insecure, anxious about rejection, and con- cerned about being inexperienced and not well equipped to help the patient process the loss of the prior therapist. It is important to note that despite the challenges and therapist trainees con- cerns about their lack of skills and training, most of the trans- fers led to continued treatment, with only one case reported as an “early termination” after about seven months.
    The Influence of Client Characteristics on the Transfer Process
    Clients were also described as influencing the transfer process. Specifically, the severity of client psychopathology was described by all but one participant as making the transfer process more difficult, which makes sense given that more severe psychopathol- ogy is related to more difficulty developing the therapy alliance even in nontransfer clients (Lingiardi, Filippucci, & Baiocco, 2005). Although it makes sense that clients with more severe psychopathology would have more difficulties losing a therapist and navigating a rupture in the alliance (Safran, Muran, & Eubanks-Carter, 2011), it is not clear the extent to which the therapists may have been attributing the difficulties in the transfers to their clients rather than their own lack of skills working with these challenges. Interestingly, although several participants did note that their prior experience dealing with particular types of clients (e.g., low functioning, schizophrenic) facilitated the trans- fer process, they rarely mentioned their lack of experience with types of client pathology as hindering their work with transfer clients.
    Another contributing client characteristic described was pref- erences about the transfer. Therapists-in-training indicated that it was facilitative when client expectations about the new ther- apist were met, whereas it was hindering when expectations were not met (e.g., a request for a therapist of a particular gender not being granted). This finding is not surprising given that the transfer was not in the clients’ control, and it makes sense that feeling as if their preferences were being taken into consideration would foster their feeling respected and valued. It is worth considering that the inexperience of the therapists-in- training may have contributed to their perception that unmet expectations were more challenging and disappointing to the
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    109THERAPIST EXPERIENCES OF TRANSFER CLIENTS
    clients. There is much empirical support for the importance of clients feeling that their preferences are heard and valued in the therapy relationship (Wampold & Imel, 2015).
    The Impact of Transfers on Therapist Sense of Identity
    According to therapists-in-training, the transfer experience had an impact on their understanding of therapy and on their profes- sional identities. Participants learned that no termination is perfect and that there will always be residual material that the client will have to process with new therapists. They also gained increased self-confidence and self-efficacy as a result of the going through transfer process, especially when clients shared information with the new therapist that they had not shared with the prior transfer- ring therapist. These results differ from those of Schen et al. (2013) who found that residents reported a great deal of distress with the transfer process, which suggests that there may be interesting variables that moderate the experience (e.g., therapist self-efficacy, clinic policies, quality of supervision).
    The Impact of Transfer on Clients
    Participants typically felt that the transfer process hindered client growth (without any positive impact). Our participants felt that in some cases, the constant change of therapists contributed to client avoidance of dealing with deeper issues. Under recommen- dations, our participants noted that many of the procedures around when these transfers occurred were geared toward the trainee (e.g., timing of transfers, should the client be transferred or referred out) and did not always take into consideration the needs of the clients. Although beyond the scope of this study, further research and discussion related to balancing the needs of clients and the needs of trainees and training clinic could be an important method for minimizing client harm.
    Therapists’ Recommendations for Transfers in Training Clinics
    Participants identified specific clinic policies that could facili- tate the transfer process. First, participants almost unanimously recommended that training facilities provide more structure and guidance around the transfer process. This recommendation was likely in response to having been provided little or no specialized training about proceeding with a transfer patient. Similarly, Schen et al. (2013) noted the need for adequately preparing trainees for transfers.
    Some of the participant recommendations included streamlining the transfer process and making it a requirement that there be a meeting between the prior therapist and the current therapist that sometimes includes the client. This meeting was suggested by those therapists who did not have a clear procedure in place and it was appreciated by those participants who were required to do so. Clearly, the importance of collaboration between the transferring and transferred-to therapists was evident in this study.
    Differences Between the Two Clinics
    Despite the differences in orientations (mainly in the use of CBT more in the SE clinic than the PP clinic), the different supervisors,
    and training facilities, there were not that many meaningful dif- ferences between the findings in the two clinics. The two main differences were that the PP clinic participants more often than SE clinic participants recommended that the new therapists process the transfer fully with the client, even if the client was resistant to processing the termination. In addition, more PP participants com- pared with SE participants described the need for meetings with new therapists, transferring therapists, and clients. One possible explanation is that such meetings were already implemented in the SE clinic and thus the SE participants did not see a need for more meetings. Given the philosophical differences between the clinics and the different personnel involved, it is surprising that there were not more differences between samples. We suggest that the simi- larities provide some evidence of the robustness of these findings across samples.
    Strengths and Limitations
    Use of two different clinics with different training philosophies allowed us to show similar findings across clinics with different procedures and processes, reducing concerns about sample- specific findings. In addition, use of highly experienced interview- ers/judges who had considerable familiarity with training clinics and the transfer process likely enabled us to provide an inside perspective on the experience. In addition, use of four judges and an auditor provided for multiple voices on the data, which hope- fully enabled us to transmit the findings with integrity.
    The goal of qualitative studies is to investigate inner experiences in great depth, which is possible only with a small number of participants. The similarity of findings, however, between the two samples and with the previous literature by both therapists (Schen et al., 2013) and clients (Clark et al., 2014, 2011; Wapner et al., 1986) is reassuring, however, and suggest that we were not just finding results specific to one setting.
    Of course, problems with bias are inherent in every type of research methodology. In qualitative research, we had the advan- tage of having consistency in the research team in terms of the same researchers developing the research protocol, conducting the pilot and actual interviews, and analyzing the data. Furthermore, the use of an outside auditor mitigated some of the concern about groupthink that can occur within a research team. In addition, the consensus method is designed to help investigators become aware of and bracket biases. The team members respected one another and felt comfortable disagreeing and discussing different perspec- tives, so we felt comfortable that multiple voices were heard and respected. The influence of bias on the results is always present, however, and as with other methods, requires replication across studies and qualitative meta-analyses to determine generalizability of results (see Hill, Knox, & Hess, 2012).
    We might speculate that therapists-in-training who volunteered to participate felt more positive about the transfer process and more confident about their clinical work compared with those who did not volunteer to participate. It is also important to note that our study focused only on the therapists’ and not the clients’ experi- ences of the transfer process.
    Another factor that might have influenced the results (although this would also have been true with a survey method) is that interviews relied on the participants’ ability to recall the experi- ence of the transfer process. Participants undoubtedly provided a
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    110 MARMAROSH, THOMPSON, HILL, HOLLMAN, AND MEGIVERN
    revisionist account of their experiences by adding, omitting, or smoothing data in order to comply with a particular narrative and to appear socially desirable in front of the interviews. The way in which the therapy ended may also have been a confounding variable that had the potential to affect the retelling of the events after the end of treatment.
    Implications for Theory and Practice
    Our findings indicate that transfers can be a challenging expe- rience for clients, who are required to develop a new relationship after a loss. Transferring can be especially difficult for clients who struggle with attachment concerns (Bowlby, 1996) and severe psychopathology. For example, there has been growing research linking client insecure attachment style and weaker working alli- ance (Bernecker, Levy, & Ellison, 2014). Individuals who are avoidant of intimacy or expect abandonment in relationships may be more likely to struggle with these types of relationship ruptures (Eames & Roth, 2000; Rubino, Barker, Roth, & Fearon, 2000). The implication is that individual differences influence the transfer and need to be taken into consideration when determining who should be transferred and when.
    In addition, our research revealed that terminating with a client who is transferring to a new trainee is different from termination in general. The most important difference is preparing the client for having a new therapy relationship, processing not only the ending of the current therapy but the fears, expectations and other emo- tions that the client might have toward the new therapist. This is especially true if the client has and expectation for a type of new therapist or a bias toward a specific gender, race, ethnicity of the new therapist. Training therapists to address race, class, gender, and bias is important during transfers where clients may be forced to work with someone different than their prior therapist or with someone who activates their stereotypes or fears (Fuertes, Mueller, Chauhan, Walker, & Ladany, 2002; Sue, 1998). Supervision is critical to help training therapist cope with their own reactions to these stereotypes and microaggressions that influence the devel- oping therapy alliance.
    By the same token, starting with a new client who has just terminated from another therapist is not the same as starting with a “fresh” client. In these situations, the new therapist must nego- tiate both the positive and negative impact of that prior therapy and prior therapist, as well as any unresolved feelings the client might be bringing into this new therapy. Most of our participants felt that although their training and preparation for seeing clients in general was sufficient, their preparation for the special issues related to transferring clients was absent or minimal. It is important for supervisors and clinic administrators to facilitate more direct train- ing on transferring clients to therapists in training. Therapists working with transfer clients may benefit from openly processing the transfer with their clients and exploring how the transition was experienced by them.
    Implications for Training and Research
    Based on these findings, there are several recommendations for training clinics that engage in transferring clients. Specifically, we recommend that there be more detailed training with regards to clarifying what type of information is helpful to pass onto the new
    therapist and what information could be disruptive. For example, it may be extremely helpful to tell the future therapist what type of interventions were useful for the client and what issues remain to be addressed. It may be less helpful to hear the prior therapist’s intense countertransference. It is not helpful to hear the prior therapist vent that the client was the worst client she had ever seen and then list off all the reasons why she is happy the treatment is ending or how she intends to work with the client in the future and gave the client her contact information. In addition to training therapists what to discuss before the transfer, there needs to be training on how to address the transfer with the client after the transfer, and help the new therapist foster an open dialogue about loss, transition, and uncertainty and be able to respond empathi- cally to the client. This may include conversations about race, class, ethnicity, gender, sexual orientation, and other differences between the prior and new therapist that influence the transfer process. These conversations can be challenging for any therapist, especially new therapists, and there needs to be training to facili- tate these dialogues (Maxie, Arnold, & Stephenson, 2006; Sue, 1998).
    Participants also addressed the need for clinic staff to be aware of how the lack of commitment to clinic policies impacts the transfer process. We had participants saying that there was an added strain on the new relationship when they were left to collect debt from prior treatment or instill policies for the first time while also building an alliance with a transfer client. Lastly, we recom- mend that clinics think more about who is transferred and consider the needs of clients with different issues and diagnoses. Not all clients should be transferred. Some clients prefer a new therapist every year because it keeps them from getting too close or depen- dent on a therapist; it may feel safer but inhibit some areas of growth. On the other hand, some clients may benefit from having a new therapist with a different perspective or approach to treat- ment. There is much we have to learn about the transfer process and very little research facilitating our understanding of it.
    The termination and subsequent transfer of clients in training clinics is an unavoidable, and frequent reality faced by clients, students in training, and supervisors. It may occur more frequently in training clinics, but it occurs in all professional settings when a therapist leaves an agency or can no longer treat the client, and the clients are reassigned to a new therapist. It also occurs in inde- pendent practice when clients leave one therapist and start with a new therapist. It is long overdue that we respond through qualita- tive and quantitative research in order to identify the best practices. In light of the research indicating high client dropout as a result of transfers (Tantam & Klerman, 1979; Wapner et al., 1986), as well as the affective distress found among the therapists-in-training during this process (Hill et al., 2007; Schen et al., 2013; current study), it is clear that more research is needed to understand, and mitigate issues raised by both clients and their therapists.
    We also need to know more about how therapist personality and training influence the transfer process and how therapist and client factors interact to predict transfer outcome. For example, Marmarosh et al. (2015) studied therapists’ percep- tions of the therapy alliance when working with their first transfer client and found that therapist attachment dimensions were related to their perceptions of ruptures with transfer clients at the eighth session of their new treatment. Specifically, they found that the greater the therapists’ attachment anxiety, the
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    111THERAPIST EXPERIENCES OF TRANSFER CLIENTS
    more tension they reported due to ruptures in their relation- ships. It appears that therapist attachment style is one factor that may influence the transfer relationship. It is likely that the clients’ attachment and interpersonal functioning would also influence this process. We could not find any studies examining how client attachment impacts the transfer process, how the interacting attachments between the client and therapist impact the therapy relationship after a transfer, how client psychopa- thology impacts the experience of being transferred, or the influence of therapist multicultural competency and or openness to diversity on transfer success. Such research is needed to help us determine the best practices when it comes to transferring clients.
    With more targeted research that identifies the mechanisms at play during the transfer process, we will be able to address concerns and encourage a proactive and positive stance toward transfers. Given the transfer process may be experienced as a rupture for clients, it would be very useful to apply the literature on rupture and repair (Safran et al., 2011) to help train thera- pists to address the transfer process successfully and to study how training interventions impact treatment outcomes for trans- fer clients. Developing specific instruments that assesses read- iness for transfer and transfer outcome could also facilitate the transition and help therapists decide on the best treatment modality for their clients. As participants said in our research, not all clients should be transferred and some may benefit from being in a therapeutic relationship where transferring frequently does not occur.
    References
    Bernecker, S. L., Levy, K. N., & Ellison, W. D. (2014). A meta-analysis of the relation between patient adult attachment style and the working alliance. Psychotherapy Research, 24, 12–24. http://dx.doi.org/10.1080/ 10503307.2013.809561
    Bowlby, J. (1969). Attachment and loss: Vol. 1: Attachment. New York, NY: Basic Books.
    Boyer, S. P., & Hoffman, M. A. (1993). Counselor affective reactions to termination: Impact of counselor loss history and perceived client sen- sitivity to loss. Journal of Counseling Psychology, 40, 271–277. http:// dx.doi.org/10.1037/0022-0167.40.3.271
    Clark, P., Cole, C., & Robertson, J. (2014). Creating a safety net: Trans- ferring to a new therapist in a training setting. Contemporary Family Therapy: An International Journal, 36, 172–189. http://dx.doi.org/10 .1007/s10591-013-9282-2
    Clark, P., Robertson, J. M., Keen, R., & Cole, C. (2011). Outcomes of client transfers in a training setting. American Journal of Family Ther- apy, 39, 214–225. http://dx.doi.org/10.1080/01926187.2010.531650
    Eames, V., & Roth, A. (2000). Patient attachment orientation and the early working alliance-a study of patient and therapist reports of alliance quality and ruptures. Psychotherapy Research, 10, 421–434. http://dx .doi.org/10.1093/ptr/10.4.421
    Fuertes, J. N., Mueller, L. N., Chauhan, R. V., Walker, J. A., & Ladany, N. (2002). An investigation of European American therapists’ approach to counseling African American clients. The Counseling Psychologist, 30, 763–788. http://dx.doi.org/10.1177/0011000002305007
    Hill, C. E. (Ed.), (2012). Consensual qualitative research: A practical resource for investigating social science phenomena. Washington, DC: American Psychological Association.
    Hill, C. E., Knox, S., & Hess, S. A. (2012). Qualitative meta-analyses on consensual qualitative research. In C. E. Hill (Ed.), Consensual quali- tative research: A practical resource of investigating social science
    phenomena (pp. 159–171). Washington, DC: American Psychological Association.
    Hill, C. E., Knox, S., Thompson, B. J., Williams, E. N., Hess, S., & Ladany, N. (2005). Consensual qualitative research: An update. Invited article in Journal of Counseling Psychology, 52, 196–205.
    Hill, C. E., Sullivan, C., Knox, S., & Schlosser, L. (2007). Becoming psychotherapists: Experiences of novice therapists in a beginning grad- uate class. Psychotherapy, 44, 434 – 449. http://dx.doi.org/10.1037/ 0033-3204.44.4.434
    Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting consensual qualitative research. The Counseling Psycholo- gist, 25, 517–572. http://dx.doi.org/10.1177/0011000097254001
    Holmes, J. (2006). Too early, too late: endings in psychotherapy – An attachment perspective. British Journal of Psychotherapy, 14, 159–171.
    Keith, C. (1966). Multiple transfers of psychotherapy patients. A report of problems and management. Archives of General Psychiatry, 14, 185– 189. http://dx.doi.org/10.1001/archpsyc.1966.01730080073011
    Ladany, N., Thompson, B. J., & Hill, C. E. (2012). Cross analysis. In C. E. Hill (Ed.), Consensual qualitative research: A practical resource of investigating social science phenomena (pp. 117–134). Washington, DC: American Psychological Association.
    Lingiardi, V., Filippucci, L., & Baiocco, R. (2005). Therapeutic alliance evaluation in personality disorders psychotherapy. Psychotherapy Re- search, 15, 45–53. http://dx.doi.org/10.1080/10503300512331327047
    Marmarosh, C. L., Schmidt, E., Pembleton, J., Rotbart, E., Muzyk, N., Liner, A., . . . Salmen, K. (2015). Novice therapist attachment and perceived ruptures and repairs: A pilot study. Psychotherapy, 52, 140– 144.
    Maxie, A. C., Arnold, D. H., & Stephenson, M. (2006). Do therapists address ethnic and racial differences in cross-cultural psychotherapy? Psychotherapy, 43, 85–98. http://dx.doi.org/10.1037/0033-3204.43.1.85
    Messer, S., & Wampold, B. (2002). Let’s face facts: Common factors are more potent than specific therapy ingredients. Clinical Psychology: Science and Practice, 9, 21–25. http://dx.doi.org/10.1093/clipsy.9.1.21
    Penn, L. (1990). When the therapist must leave: Forced termination of psychodynamic therapy. Professional Psychology: Research and Prac- tice, 21, 379–384. http://dx.doi.org/10.1037/0735-7028.21.5.379
    Rubino, G., Barker, C., Roth, T., & Fearon, P. (2000). Therapist empathy and depth of interpretation in response to potential alliance ruptures: The role of therapist and patient attachment styles. Psychotherapy Research, 10, 408–420. http://dx.doi.org/10.1093/ptr/10.4.408
    Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48, 80–87. http://dx.doi.org/10.1037/ a0022140
    Schen, C. R., Raymond, L., & Notman, M. (2013). Transfer of care of psychotherapy patients: Implications for psychiatry training. Psychody- namic Psychiatry, 41, 575–595. http://dx.doi.org/10.1521/pdps.2013.41 .4.575
    Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53, 440–448. http://dx.doi.org/10 .1037/0003-066X.53.4.440
    Super, S. (1982). Successful transition: Therapeutic interventions with the transferred client. Clinical Social Work Journal, 10, 113–122. http://dx .doi.org/10.1007/BF00757618
    Tantam, D., & Klerman, G. (1979). Patient transfer from one clinician to another and dropping–out of out-patient treatment. Social Psychiatry, 14, 107–113. http://dx.doi.org/10.1007/BF00582175
    Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: Research evidence for what works in psychotherapy (2nd ed.). New York, NY: Routledge.
    Wapner, J. H., Klein, J. G., Friedlander, M. L., & Andrasik, F. J. (1986). Transferring psychotherapy clients: State of the art. Professional Psy- chology: Research and Practice, 17, 492–496. http://dx.doi.org/10 .1037/0735-7028.17.6.492
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    112 MARMAROSH, THOMPSON, HILL, HOLLMAN, AND MEGIVERN
    http://dx.doi.org/10.1080/10503307.2013.809561
    http://dx.doi.org/10.1080/10503307.2013.809561
    http://dx.doi.org/10.1037/0022-0167.40.3.271
    http://dx.doi.org/10.1037/0022-0167.40.3.271
    http://dx.doi.org/10.1007/s10591-013-9282-2
    http://dx.doi.org/10.1007/s10591-013-9282-2
    http://dx.doi.org/10.1080/01926187.2010.531650
    http://dx.doi.org/10.1093/ptr/10.4.421
    http://dx.doi.org/10.1093/ptr/10.4.421
    http://dx.doi.org/10.1177/0011000002305007
    http://dx.doi.org/10.1037/0033-3204.44.4.434
    http://dx.doi.org/10.1037/0033-3204.44.4.434
    http://dx.doi.org/10.1177/0011000097254001
    http://dx.doi.org/10.1001/archpsyc.1966.01730080073011
    http://dx.doi.org/10.1080/10503300512331327047
    http://dx.doi.org/10.1037/0033-3204.43.1.85
    http://dx.doi.org/10.1093/clipsy.9.1.21
    http://dx.doi.org/10.1037/0735-7028.21.5.379
    http://dx.doi.org/10.1093/ptr/10.4.408
    http://dx.doi.org/10.1037/a0022140
    http://dx.doi.org/10.1037/a0022140
    http://dx.doi.org/10.1521/pdps.2013.41.4.575
    http://dx.doi.org/10.1521/pdps.2013.41.4.575
    http://dx.doi.org/10.1037/0003-066X.53.4.440
    http://dx.doi.org/10.1037/0003-066X.53.4.440
    http://dx.doi.org/10.1007/BF00757618
    http://dx.doi.org/10.1007/BF00757618
    http://dx.doi.org/10.1007/BF00582175
    http://dx.doi.org/10.1037/0735-7028.17.6.492
    http://dx.doi.org/10.1037/0735-7028.17.6.492
    Appendix
    Transfer Study Interview Protocol
    1. Please tell me in general about your overall experience of seeing clients for the first time in this training clinic.
    2. Describe your experience with transfer clients in this training clinic.
    3. Describe any particular training that you received to prepare you for your work with transfer clients in this training clinic.
    4. Describe things about you personally that enhanced and challenged your work with transfer clients.
    5. Describe things about the CLINIC that enhanced or hindered your work with transfer clients.
    6. Describe the transfer process with a particular client. Tell me about the client.
    7. Did you speak to the client’s previous therapist? If so, what was your experience like?
    If not, what stopped you from talking with the client’s previous therapist? How do you think it would have helped/hindered the therapy to talk to the previous ther- apist?
    8. How do you feel the previous therapist had an impact on the transfer process? Specifically, how do you feel the therapeutic work with the previous therapist had an impact on the transfer process?
    9. Sometimes people seek out prior information about the case beforehand, what information did you explore? How did you use the prior treatment documentation to aid the current treatment? What was your rationale for reviewing or not reviewing this documentation? In what ways was reviewing this documentation helpful or un- helpful to you in the transfer process?
    10. Sometimes client variables influence the transfer pro- cess, such as race/ethnicity, age, gender, relationship history—What, if any, variables related to the CLIENT influenced the transfer process? And how? What, if any, variables related to you, the therapist, influenced the transfer process?
    11. Describe the course of treatment with this transfer cli- ent. (e.g., How many sessions did you see this client? Is it ongoing or did it end? How frequently did you see this client? What were some of the issues worked on? Based on the client’s history, did you expect more or less difficulty with the transfer process? What way, if any, did the client’s relationship history influence the trans- fer process? How do you imagine that your working alliance facilitated or hindered the transfer process?).
    12. Please describe the kind of supervision you received for the transfer aspects of this case from your supervisor.
    13. In working with this particular client, what support would you have liked to receive more or less of and from whom?
    14. In what ways did this experience have an impact on your sense of self as a therapist and your professional identity?
    15. When in your practicum/internship training did you start seeing this client?
    16. Overall, how did working with these transfer clients have an impact on your sense of efficacy and develop- ment as a therapist?
    17. What do you think would have enhanced this experience for you as a therapist and for your clients?
    18. Describe how your experience working with transfer clients was similar to or different from your experience working with nontransfer clients in the clinic?
    19. What recommendations do you have about how this transfer process could be improved for future therapists in training like yourself?
    20. What recommendations do you have about how this transfer process could be improved for clients?
    Received April 28, 2016 Revision received September 2, 2016
    Accepted September 4, 2016 �
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    113THERAPIST EXPERIENCES OF TRANSFER CLIENTS
    Therapists-in-Training Experiences of Working With Transfer Clients: One Relationship Terminates …
    The Impact of Transfers on Clients: Empirical Findings
    The Impact of Transfers on Therapists-in-Training: Empirical Findings
    Purpose of the Current Study
    Method
    Data Set and Description of Clinics and Client Population Served
    Trainee Participants
    Measures
    Demographic form
    Interview protocol
    Procedure
    Selection of participants
    Interview
    Data analysis
    Results
    Prior Therapist Characteristics That Influenced the Transfer Process
    Facilitating characteristics
    Hindering characteristics
    Characteristics of Current Therapist That Influenced the Transfer Process
    Facilitating characteristics
    Hindering characteristics
    Client Characteristics That Influenced the Transfer Process
    Facilitating characteristics
    Hindering characteristics
    Impact of the Supervisor on Transfer
    Facilitating characteristics
    Hindering characteristics
    Characteristics of the Training Clinic
    Facilitating characteristics
    Hindering characteristics
    Influence of Transfer on Therapist Participants
    Influence of Transfer on the Transfer Client
    Difference Between Transfer and Nontransfer Clients
    Recommendations for Transfers in Training Clinics
    Discussion
    Influence of Transferring Therapists
    Influence of Transferred-to Therapists on Transfers
    The Influence of Client Characteristics on the Transfer Process
    The Impact of Transfers on Therapist Sense of Identity
    The Impact of Transfer on Clients
    Therapists’ Recommendations for Transfers in Training Clinics
    Differences Between the Two Clinics
    Strengths and Limitations
    Implications for Theory and Practice
    Implications for Training and Research
    References
    Appendix Transfer Study Interview Protocol

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