Client crying in the context of family therapy:an exploratory study

Loreto Cuevas-Escorzaa andMiguel Garrido-Fernándezb

This study explores the crying episodes of twenty-eight clients treatedat a family therapy service in a community centre. The crying episodeswere associated with some significant elements: the time of appearance,the content and triggering factor, the interpersonal context of sessionsand the emotions clients had for the therapist, as well as the therapy’soutcome (end of treatment and the satisfaction of clients). Crying wasmuch more frequent during the first session. It occurred more fre-quently when there was another family member present. The proportionof clients who cried during the treatment was significantly higher forclients who completed it successfully. Clients who cried perceived thetherapist, in all cases, as a kind person who never got annoyed with them.Crying could be considered a type of behaviour that helps the therapistto create a safe context and foster the therapeutic alliance.

Keywords: psychotherapy and non-verbal communication; crying; therapeuticalliance; reflecting team; family therapy.

Crying is essentially a human capacity (Barbalet, 2005; Vingerhoetset al., 1992) that allows us to express feelings and emotions that aredifficult to express with words. Darwin (1872) defined crying as anatural and primary behaviour to express suffering. Though tearsmay have originally had a cleaning function in the human cornea,their evolution has made them part of a non-verbal communicationsystem that expresses feelings and emotions. Like other elements ofnon-verbal communication, crying complements the communicationestablished on the verbal level. Thus, crying as an indicator of certainemotions plays a very important role in defining the relationship

a Lic.Loreto Cuevas-Escorza, Universidad de Sevilla, Personalidad, Evaluación yTratamiento Psicológicos-Facultad de Psicología. S/N Sevilla 41018 Spain. E-mail: maikel@us.es.

b Dr Miguel Garrido-Fernández, Evaluación y Tratamiento Psicológicos-Facultad dePsicología, Universidad de Sevilla, Spain.

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Journal of Family Therapy (2012) ••: ••–••doi: 10.1111/j.1467-6427.2012.00596.x

© 2012 The AuthorsJournal of Family Therapy © 2012 The Association for Family Therapy and Systemic Practice. Published byBlackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA02148, USA.

when it occurs in an interpersonal context. We could assert that as anon-verbal expression of emotions, crying takes on communicativemeaning when studied in relation to the communication context inwhich it is exhibited (Watzlawick et al., 1967).

Crying is a form of communication. For instance, some authorspoint out that for babies this non-verbal conduct is used to get theattention of caregivers (Bowlby, 1969). Crying is one of the firstmechanisms that newborns have in their behavioural repertoire toexpress discomfort (Boukydis, 1985) and it soon becomes a means toinfluence others. The translation of infant crying in terms of averbal message could be the equivalent to ‘Come here, I need you,’on many occasions (Nelson, 2000). In general, the capacity to cryand express oneself adequately through crying can be regarded asvery adaptive non-verbal behaviour, since it frequently brings abouthelpful responses when done in the presence of others (Kottler,1996).

What communicative role does crying play in the interpersonalcontext of psychotherapy? Can crying, as a sign of vulnerability andan expression of the need for help, be a significant indicator of thetherapeutic process? Undoubtedly, the answers to these questions arenot simple and include multiple theoretical perspectives; and thisstudy is intended to provide an exploratory and empirical response tothese questions.

In the literature on psychotherapy there have been very differenttheoretical interpretations of the function of crying. Thus, forinstance, from a psychoanalytical viewpoint, crying has been inter-preted as a symbol of regression to an intrauterine state (Heilbrunn,1955) or as a defensive behaviour against other internal energies.Sometimes psychoanalysis has viewed crying as a safety valve which,when opened, releases blocked pain (Lofgren, 1966; Sachs, 1973).Crying has been studied as one of the most important drives forself-preservation (Winnicott, 1958). At the same time, in the thera-peutic setting, transference to the analyst will facilitate the expressionof emotions and become one of the most important curative factors inworking with regression and separation anxiety (Kohut 1984). Cryinghas also been portrayed as a therapeutic regression that is related toremembering and to the repetition of painful situations and, at thesame time, to the need to treat conflicts in a safe setting (Luborsky andAuerbach, 1985).

From the studies on attachment, the importance of crying has beenunderscored as the expression of emotions that can contribute to the

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creation of mutuality and help relationships (Nelson, 2007). Moreo-ver, client-focused therapy (Rogers, 1951) indicates that the patient’scrying can let both others and the patients themselves know thatsomething significant is happening inside them which may not bevisible from the outside.

In the context of systemic family therapy, crying has not been thefocus of specific observation; it has been simply one more element inthe emotional field. However, the emotional field does not have acentral significant role either in the tradition or in the development ofsystemic family therapy. Although there have been traditional modelsof systemic therapy that emphasized emotions (Satir, 1967; Whitaker1989) or dealt with emotions as the focal point of treatment in couples(Greenberg and Johnson, 1988; Greenberg and Goldman, 2008;Johnson and Whiffen, 2003, Johnson et al. 2005), it could be said thatemotions have not constituted a central theoretical focus for systemictherapies. However, a decade ago, certain authors began to voice theneed to pay more attention to the role of emotions as a mediator orfacilitator of change in systemic therapies (Brubacher, 2006; Millerand de Shazer, 2000).

The creation of a therapeutic alliance offers us an interesting per-spective for analysing emotional behaviour such as crying in thecontext of psychotherapy. In individual psychotherapy the alliancehas been defined as the quality and strength of the relationshipbetween the client and therapist, in which several elements arevalued: the emotional bond of mutual trust and the respect betweenthe client and the therapist and their consensus and commitment tothe goals and the therapeutic procedures or tasks employed to attainthese goals (Bordin, 1979; Horvath and Bedi, 2002). In the context offamily therapy, there are some elements of the therapeutic alliancethat can be considered unique or distinctive (Friedlander et al., 2006;Pinsof, 1995; Sprenkle and Blow, 2004). Creating a safe environmentis one of the elements considered especially important in familytherapy. This safe environment should make it possible to neutralizeor handle negative or conflictual interactions that frequently occuramong the family members who attend the therapy sessions. (Fried-lander et al., 2006). Another essential aspect is the need for striking abalance (equilibrium) in how the therapist forms alliances with each ofthe therapy participants, as well as creating an intra-family alliancelevel (among the family members who attend the therapy session),which allows conjoint treatment to develop (Escudero et al., 2010;Higham et al., 2012; Pinsof, 1995).

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From this conceptual framework of the therapeutic alliance, thisstudy starts from a generic question with clear clinical implications:What does a client’s crying at an initial family therapy session rep-resent for the therapeutic alliance? Sometimes tears can become partof defensive or manipulative behaviour. However, it often seems thatwhen clients cry they are expressing strong feelings of suffering andtherefore calling attention to their need to be helped or comforted.Even if tears have a defensive significance, it is necessary to considerthat within the therapeutic context crying may be a sign of sufferingand a call for help. Therefore, it may be said that clients areshowing vulnerability and opening up emotionally, which indicatesthat they accept therapy as a safe setting.

In the model developed by Friedlander and Escudero to analysethe therapeutic alliance in conjoint family therapy sessions (Escu-dero et al., 2010; Friedlander et al., 2006), crying is an expression ofvulnerability and emotional plasticity that can be interpreted as apowerful indicator of safety in the therapeutic system. Safety, as aconstitutive dimension of the therapeutic alliance, is defined asfollows:

The client viewing therapy as a place to take risks, to be open andflexible; a sense of comfort and an expectation that new experi-ences and learning will take place, that good can come from beingin therapy, that conflict within the family can be handled withoutharm, that one need not be defensive. (Friedlander, et al., 2006,p. 276)

The observational instrument developed by Friedlander et al. (2006)to evaluate the quality of the therapeutic alliance system for observ-ing family therapy alliances (SOFTA), provides the therapist with asingular opportunity to show empathy and an emotional connectionwith the client. According to this interpretation of how crying canhelp to create an adequate therapeutic alliance, its appearance intherapy might be a good indicator of treatment adherence and thushelp to predict the success of treatment.

From such a conceptual perspective, the purpose of this study isto explore the relationship of crying episodes observed in a sampleof twenty-eight family therapy cases, with other significant elementsof the process (time, content and reason for crying, interpersonalcontext of the session and emotions towards the therapist) and theoutcome of the therapy (end of therapy and the clients’ satisfactionwith therapy).

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Method

Participants

The study was conducted at the family therapy unit (Servicio deOrientación y Terapia Familiar, SOTF) of a community social servicescentre of a municipality located in a working-class urban area in thesouth of Spain. The sample consisted of twenty-eight patients ran-domly chosen among all the individuals treated for the first time atthe SOTF during the 4 years prior to the beginning of the study. Intwenty of the cases, more than one family member was involved intherapy, and for the other eight cases, only one client attended thetherapy sessions. Of all patients treated in SOTF during the past 4years, those with a completed application form were selected inorder to gather the socioeconomic variables and the patients’ reasonsfor applying. Other requirements were the patient was attending forthe first time and completed treatment regardless of the reasons forseeking it. The eight individual therapy patients were included inspite of the fact that the systematic approach carried out at theCentre would normally involve meeting family members duringtreatment, but in some cases the uncooperativeness of familymembers made this impossible. Since the main objective of the studywas to assess the role of crying in facilitating the therapeutic alliance,and not the role of crying before family members, removing theseeight individuals from the study was not deemed to be necessary.All patients gave their informed consent following the model used inthe SOTF for the recordings and their subsequent use in research.This study took the person making the request as the identifiedpatient.

A total of 83 per cent of the sample consisted of women (age:M = 40 years, SD = 10.2, range = 20–62 years). Men, who constitutedthe remainder of the sample (17%), were within an age range of20-40 years with a mean age of 29 years. More than half the clients(51.7%) were married and just 55.6% of them had finished elemen-tary school (55.6%). Therefore, most participants were women with alow educational and socioeconomic level. Of the twenty-eight patientswho comprise the sample, 93% of families were referred by the socialservices, 82% had children less than 20 years of age and 36% weresingle parents. The treatment consisted of a mean of twelve sessions(with a range of 1–22 sessions). The mean duration of sessions was 80minutes, and the reflecting team intervened once per session for 5 to10 minutes.

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Half of the twenty-eight families studied acknowledged that whenthe treatment ended, their planned objectives had been attainedaccording to the family’s initial request; for these patients with sat-isfactory endings, the mean number of sessions was eleven (with arange between a maximum of twenty-two and a minimum of sixsessions). Of the other fifteen, the mean number of sessions was four(with a range between a maximum of seven sessions and a minimumof one session).

The mean age of the seventeen therapists who participated in thestudy was 26 years (range = 23–40 years) and their mean years ofexperience and training was 4 years (range 2–15 years); 23.5% oftherapists were men and 76.5% women. Patients were assigned totherapists on an available basis. Every professional attended amaximum of two cases as principal therapist, though on some occa-sions the same therapists formed part of the reflecting team. Alltherapists had a masters’ qualification in family therapy and anaverage of 3 years of training, with a range of 1–5 years and a clinicalexperience of 2–15 years, with an average of 6 years. All the therapistswere supervised.

Instruments

In the process-outcome inventory the reason for the consultation iscarefully recorded, and each patient’s stated need is classified intofour categories: individual, familiar, parent–child and couple. In addi-tion, the reason for which the client ended treatment was divided intotwo categories: completed treatment, and client dropout. Likewise,the questionnaire includes a register of the number and format of thesessions held (individual, couple, family).

The follow-up questionnaire, which was conducted by telephone,consists of nineteen follow-up questions with three level, Likert-typeanswers (1 = never; 2 = sometimes; 3 = always) and was administered3 months after the end of the treatment. Clients could choose theresponse that best reflected their own experience or the experience ofthe family in therapy: affection for the therapist, annoyance with thetherapist and the therapist’s kindness as perceived by the client, aswell as the possibility of going back into therapy in the future ifnecessary. The information shows that most (95%) of those who criedwere both women and mothers.

The crying episodes observation system (Cuevas, 2006), wasdesigned specifically for this study and applied to all the sessions of

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the sample. All sessions were routinely video-recorded (with theclients’ informed consent). The coding system for the crying episodesis a simple guide for the detection, recording and transcription of theminute before and after the first time a client cried. Crying episodeswere recorded if tears were clearly shed and the act of drying themwas observed. The verbal content that was given in the minute beforeand after the episode of the crying was also codified.

Procedure

This study, naturalistic in nature, preserved the usual treatment con-ditions followed at the family therapy service. Treatment was notsubject to any restrictions, except for the video-recording of sessionswith the prior consent of the clients. All clients were voluntary appli-cants for the treatment and signed an informed consent form in orderto be included in the study. The type of treatment employed with thefamilies included in the sample was therefore the one usually appliedat the SOTF, a Spanish adaptation (Garrido and Fernández-Santos,1997) of the brief systemic-constructivist therapy model with reflect-ing team (Andersen 1991).

All the sessions with the twenty-eight patients were viewed by thetwo evaluating judges who recorded the number of the session andthe exact temporal moment in which any family member participatingin the therapy cried for the first time. A research assistant transcribedthe minute before and after all the crying episodes, in order to codewho and what content triggered crying. The judges analysed thesessions and reached a consensus on the crying episodes from thetranscriptions and video-recordings in order to categorize the reasonand content associated with the crying episode. The analysis of thecrying episodes was done after information was gathered on theoutcome and follow up of cases, but the observers were blind to anyinformation about those variables. Of the twenty-eight patients of thestudy, only twenty completed the questionnaire (six who did not cry,and fourteen of the twenty-two who cried).

Results

Crying in the treatment context was very frequent. There was a cryingepisode in twenty-two of the twenty-eight patients analysed (78.6%).Crying was much more frequent in the first session than in any other;occurring in the first session in twelve out of the twenty-two patients

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(54.5%). In the other ten patients with crying episodes, these episodeswere homogeneously distributed between sessions two and six, andthe number of crying episodes never exceeded three. The relation-ship between crying and the number of the therapy session in whichthe episode occurred is significant (c2

= 23,818, P = 0.00).Crying occurred more frequently when there was another member

of the family present at the session. Concretely, in 59% of cases, cryingoccurred when the client who cried was accompanied by a familymember in the session; and crying occurred in only one case in whicha client was not accompanied in the session. The association of cryingwith the interpersonal context variable (being accompanied or not inthe session) was statistically significant (c2

= 9,9009, P = 0.007).The cross relationship between crying and the variables: the verbal

content that was given in the previous and the next minute in theepisode of crying and reason for consultation also turned out to bestatistically significant (c2

= 20,700, P = 0.001), so that the proportionof clients who cried while they talked about the topics specified in thereason for consultation is significantly higher than expected bychance. Likewise, in both the clients who went into therapy for tworeasons and in those who did so for only one reason, the context ofcrying is connected with one of the two reasons that made them resortto therapy.

One of the objectives of the study was to explore the relationshipbetween crying and the way in which a decision was made to endtreatment (either because the objectives established in the therapywere attained or because the client decided to abandon the treat-ment without fully attaining the objectives set at the beginning oftherapy). In so far as crying was defined as an indicator of safety inthe therapeutic system, according to the system for observing familytherapy alliances (Friedlander et al., 2006), in all the patients ana-lysed in this study, crying was expected to work as a treatment facili-tator. The results confirmed a significant relationship between theexistence of crying episodes and the successful completion of thetreatment (c2

= 9,333 P = 0.002). The proportion of clients who criedand whose treatment ended successfully is significantly higher thanexpected by chance (standard residual value = 3.1, P � 0.01) (seeTable 1).

One of the exploratory objectives of the present study was toanalyse whether crying could be associated with the client’s perceptionof the therapist. This variable was reflected in the study by thefollow-up questionnaire that gathered information about the clients’

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perceptions of annoyance with the therapist and the therapist’s kind-ness. The results from the analysis of these variables with relation tothe crying episodes indicate that the fourteen clients who cried atsome point during treatment and completed the follow-up question-naire always perceived the therapists as kind and were never annoyedwith them. The negative relationship between crying and annoyancewith the therapist is shown in Table 2 (c2

= 8,235, P. 0.002). Althoughthe relationship between crying and therapist’s kindness was not sta-tistically significant, it could be relevant if we only take into accountthe clients who cried: all of whom perceived the therapist as beingkind.

Discussion

The results of this study show that clients usually cried in the presenceof another family member in the session (thirteen of twenty-two, 59%),and the crying episode was connected with the reason that led them toresort to therapy (nineteen of twenty-two cases, 86.36%), as evidencedby the statistical significance of the variable company and the positivecorrelation between the reason for crying and reason for the consul-tation variables. These results suggest there is an important relationalmeaning to crying: its communicative value as a non-verbal element.

TABLE 1 Relationship between crying and the treatment’s final outcome

Crying

TotalNo Yes

End of treatment Objectives attained 0 14 14Objectives not attained 7 7 14

7 21 28

TABLE 2 Analysis of the relationship between crying and reports on being annoyed withthe therapist

Annoyance

TotalNever Sometimes

Crying No 3 3 6Yes 14 0 14

Total 17 3 20

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The studies on crying in the general population indicate that adultsmay cry when alone (Frey, 1985; Vingerhoets and Becht, 1996) butwhen this behaviour takes place in the presence of others, it is usuallydisplayed in front of a significant other (Williams, and Morris, 1996).Kottler (1996) pointed out that crying is a non-verbal form of com-munication that expresses a need for help. Based on this conceptu-alization of crying, the results of our exploratory study reaffirm theidea that crying is triggered most frequently by the client (36.4%),perhaps with the intention, either consciously or unconsciously, ofemotionally involving the therapist and the family member in a com-mitment to help them.

However, since according to our results crying is more likely to takeplace in the first session (54.5%), it is clearly very important to createa warm and helpful atmosphere from the beginning. A study byRaytek et al. (1999) found that for couples who did not complete thetreatment programme, the therapeutic alliance was weaker after thefirst session than those who did. This suggests that the perception ofthe therapist that clients developed during the first session was relatedto their decision to continue with the treatment. These findings indi-cate that the construction of the alliance could be one of the mostimportant therapeutic tasks of the first session.

As crying usually takes place in the first session, it seems reasonableto think that crying could significantly influence the client’s percep-tion of the therapist, since the therapist is not yet someone significantfor the client. However, causality cannot be inferred from a descrip-tive study.

The therapist’s response to tears will determine whether or notindividual clients feel that the therapeutic context is a safe space inwhich they can be accepted unconditionally. Inversely, it could be saidthat clients show their vulnerability and acceptance of therapy bycrying when the therapist has been capable of creating a safe contextthat reflects a strong therapeutic alliance. In any case, irrespective ofthe fact that the therapist’s behaviour which facilitates the therapeuticalliance may bring about crying or may be an adequate response to it,the results from this study confirm the crying episodes to be a sign ofa good therapeutic alliance in so far as they reflect the client’s abilityto express their vulnerability and need for help.

As part of the interpretation of crying as an expression of safety inthe therapeutic system, and therefore, as a sign of the therapeuticalliance (Friedlander et al., 2006), we could also suggest that the act ofcrying serves in many cases as a test, as if clients use it to ask the

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therapist whether the therapeutic context is safe enough for them toreveal their inner feelings and thoughts (Kottler, 1996). Thus, tearswould turn out to be a message that allows therapists to go deeper intotheir relationships with their clients.

The results of the study also confirm the positive associationbetween the crying and completion of treatment variables: all theclients who completed the treatment successfully cried. This resultleads us to view crying as a very significant expression of the client’sconfidence in the therapeutic context. At least in the type of centre inwhich this study was conducted, crying showed a great predictivecapacity by itself. Crying could be considered to be the clients’ clearestand most effective way to show their vulnerability to another familymember in front of a therapist. In fact, these clients never got annoyedwith the therapist and always perceived the therapist as being kind, asshown by the association between the crying episodes and the vari-ables annoyance and kindness. Our study allows us to say that cryingcan be seen as a resource that can help the therapist to generatea context in which the client will perceive therapy to be safe andthus facilitate a positive therapeutic alliance through the therapist’sresponse to tears. Studies about how therapists react to clients’ emo-tions (Garrido and Espina 1995; Garrido et al., 2009) state the impor-tance of taking into account the interdependence of mutual feelings inthe therapeutic context. The present study could be expanded withthe analysis of the therapists’ emotions once the client cries, and alsoby contrasting cases in which it is difficult for therapists to createan atmosphere that facilitates crying. It would be interesting, forexample, to analyse sessions with crying prior to therapy dropout tocheck whether it was not possible for the therapist to establish a safeatmosphere in which clients could express their emotions.

It is necessary to indicate some important limitations of this study.The instruments used are not standardized. Another limitation is theinclusion of individual therapy with couple and family therapy. Theliterature on how the expression of emotions relates to gender makesus think that the low number of male clients in the study may consti-tute a determining factor when it comes to generalizing its results.Almost 90% of clients and 76.5% of therapists were women. A studywith a more accurate balance in terms of the gender of the clients andtherapists would allow us to examine the possible influence of thegender variable and the role that gender plays. Furthermore, theresults of this sample of clients may need to be interpreted in the lightof a very specific cultural context, that is, an urban lower-class area in

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the south of Spain. The level of expressiveness and the communica-tive style of the community where the study was conducted may be acultural characteristic. Therefore, a combination of specific elementsrelated to culture and gender may have an influence on the frequencyand impact that crying has had on the therapeutic process in thisstudy. Nevertheless, this small-scale study points to the value of cryingin family therapy contexts and contributes once more to there-evaluation of emotion as a systemic concept (Pocock 2010).

Acknowledgement

We thank the social services of the Seville and Alcala de Guadairamunicipalities for their cooperation and support of this project.

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