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1. Assessing silent processes in psychotherapy: an empirically derived
categorization system and sampling strategy
ZE’EV FRANKEL1
, HEIDI M. LEVITT1
, DAVID M. MURRAY1
, LESLIE S.
GREENBERG2
, & LYNNE ANGUS2
1
University of Memphis, 2
York University
(Received 12 January 2005; revised 24 August 2005; accepted 26 August 2005)
Abstract
Silences in the three best and three poorest outcome dyads of client-centered psychotherapy in the York Depression Project I
were coded using the Pausing Inventory Categorization System (PICS). Across 90 sessions, 1,503 silences of 3 s or longer
were coded. In accordance with the hypotheses proposed by the PICS, the good-outcome dyads exhibited more emotional,
expressive, and high reflective silences and fewer disengaged and interactional silences than the poor-outcome dyads. Three
sampling strategies were compared with the complete census of silence data: one sampled the first three, middle three, and
last three sessions, whereas the other 2 randomly sampled either a quarter or a half of every session. The one-half random
sampling strategy provided results closest to the complete census. The PICS now can be situated as a process measure with a
conceptual basis in qualitative research on clients’ experience, high clientrater and interrater reliability, validation by
means of quantitative research on outcome group differentiation, and an empirically tested sampling method.
Silences in psychotherapy are not as rare as the
designation ‘‘talk therapy’’ might lead us to assume.
In fact, one study found an average of more than
5% silence in 425 one-min segments drawn from
nine clinical interviews (Sharpley Harris, 1995).
In an attempt to understand this frequent event
in psychotherapy, some investigators have explored
the phenomenon of silence within a theoretical
framework, whereas others have investigated it
empirically.
Despite the fact that psychotherapeutic silence
now tends to be seen as a heterogeneous, multi-
determined phenomenon stemming from various
underlying processes (e.g., Levitt, 2001a; Sabbadini,
1991; Wrixon, 1993), the early psychological litera-
ture described silence primarily as a homogeneous
event. For instance, silences often were tabulated
together as an indicator of resistance, empathy, or
information processing (e.g., Auld White, 1956;
Matarazzo Weins, 1977; Siegman Pope, 1972).
The appreciation of the complexity of silences first
emerged in the theoretical psychotherapy literature,
where attention gradually shifted to the varied
meanings attributable to silences and to the dangers
of generalizing or oversimplifying the nuances
inherent in silence (e.g., Greenson, 1961; Zeligs,
1961). Within the last decade, however, empirical
investigations of silence began to demonstrate the
different types of silences as well and to investigate
their effects within psychotherapy (e.g., Hill,
Thompson, Ladany, 2003; Ladany, Hill, Thomp-
son, O’Brien, 2004; Levitt, 2001a, 2001b, 2002).
These empirical findings together with the theore-
tical literature (e.g., Trad, 1993; Zeligs, 1961)
suggest that, although some silences may alert
therapists and researchers to processes potentially
hindering progress in psychotherapy, other silences
may signal engagement in change and growth.
The most programmatic inquiry into clients’
experiences of psychotherapeutic silences has been
conducted by Levitt (1998b, 2001a, 2001b, 2002),
who conducted a grounded theory analysis (Glaser
Strauss, 1967) of interpersonal process recall
(IPR) interviews (Kagan, 1975) with clients to
learn about these moments and the experiences
that they contain. Her analysis identified seven types
of silent client processes*mnemonic, associational,
disengaged, interactional, reflective, emotional, and
expressive*and led to the Pausing Inventory Cate-
gorization System (PICS; 1998a). The model
achieved saturation, which implies in the grounded
theory method that new data did not appear to lead
to the development of new categories and that the
analysis was comprehensive. These seven types of
Correspondence: Ze’ev Frankel, The University of Memphis, 101 Wilder Tower, Memphis, TN 38152-3520. E-mail: zfrankel@
memphis.edu
Psychotherapy Research, October 2006; 16(5): 627638
ISSN 1050-3307 print/ISSN 1468-4381 online # 2006 Society for Psychotherapy Research
DOI: 10.1080/10503300600591635

2. silent processes were conceptualized heuristically as
falling within three categories: neutral silences,
obstructive silences, and productive silences.
In the process measure literature, researchers’
attempts to ameliorate the time-intensive nature of
coding have led to widely different strategies in
determining the sample of psychotherapy units to
be rated. Although some psychotherapy researchers
have argued that entire psychotherapies need to be
studied to adequately assess the pattern of treatment
(Kiesler, 1973), researchers of silence in psychother-
apy have investigated randomly selected portions of
sessions (Hargrove, 1974; Staples Sloan, 1976),
single sessions (Ellgring Scherer, 1996; Matar-
azzo, Hess, Saslow, 1962; Sharpley Harris,
1995), or beginning, middle, and ending (BME)
sessions (Cook, 1964; Goldenberg Auld, 1964)
within treatments. This BME strategy is used
commonly in process measure research but is rarely
assessed for its appropriateness (e.g., Cook, 1964).
The present study aims to assess the hypotheses
put forth in the qualitative investigations that led
to the PICS: namely, that productive silences
would occur more frequently within good-outcome
dyads, whereas obstructive silences would occur
more frequently within the poor-outcome dyads
and neutral silences would not differ substantially
between outcome groups. Support for these hypoth-
eses would validate the PICS model of understand-
ing silences and would facilitate the understanding of
silent processes in psychotherapy. Toward this end,
six complete psychotherapies were coded using the
PICS, and the outcome groups were compared on
the occurrence of the seven types of silences and
on the grouping of silence types into productive,
obstructive, and neutral categories.
A secondary aim was to identify an empirically
supported sampling strategy that may reduce the
time intensity of silence coding. With just six dyads,
a complete census required a significant time invest-
ment for each coder to train, to time silences and
apply the PICS, and to enter data. That workload
presents a barrier to the use of the PICS and the
motivation to identify a sampling scheme that could
make this coding process less onerous yet provide an
accurate summary of the silences in future studies.
Toward this end, three sampling strategies were used
with the data, and the three strategies’ results were
compared with the total census of silence coding
data to determine their relative veracity. Two of the
sampling strategies were chosen based on sampling
theory, which suggests that simple random sampling
can provide an unbiased estimate of the phenom-
enon of interest when it is possible to enumerate the
entire sample (Kish, 1965), whereas the third was
based on the BME method of sampling commonly
used by psychotherapy process researchers.
Method
Participants
Clients. Five Caucasian women and one man
participated (mean age/43 years, range/2958).
All met the Diagnostic and Statistical Manual of
Mental Disorders (American Psychiatric Association,
1987) criteria for major depressive disorder and
received a score of 50 or more on the Global
Assessment of Functioning Scale. The clients did
not report any of the following: suicide attempts in
the past year, a history of incest, more than two
major depressive episodes in their lifetime, receiving
another treatment or medication for depression,
losing a significant other in the previous year,
abusing drugs or alcohol, or being in a current
abusive or violent relationship. Neither did the
clients meet criteria for eating disorder, antisocial
personality disorder, borderline personality disorder,
bipolar disorder, or any psychotic disorder. A total of
97 sessions were conducted with the 6 clients (mean
number of sessions/16.16, range/1418). Seven
of these sessions either were not recorded or were
recorded too poorly to be decipherable, leaving 90
sessions to be coded (the difference between the
good-outcome and poor-outcome groups’ numbers
of undecipherable sessions was not significant; Fish-
er’s exact test, p/ 1).
Therapists. The six psychotherapies were con-
ducted by six different psychotherapists, five women
and one man, all Caucasian. The therapists were
either advanced doctoral students in clinical psy-
chology, clinical psychologists, or psychiatrists. All
had received extensive training in empathy and
client-centered psychotherapy (at least 2 years), in
accordance with a manual (Greenberg, Rice,
Watson, 1994) prepared for the study, and possessed
an average of 5.5 years experience conducting
psychotherapy.
Silence coders. Two 30-year-old Caucasian doctoral
students in clinical psychology, 1 man and 1 woman,
coded the silences. Each coder coded 47 to 48
sessions; five sessions were coded by both coders for
interrater reliability analyses.
Measures
PICS (Levitt, 1998a). The PICS is a measure
of seven silence types that has been shown to have
high interrater (Cohen’s k/0.82) and client-rater
628 Z. Frankel et al.

3. (k/0.83) reliability and has accrued validity from its
development in a grounded theory analysis of
clients’ descriptions of their in-session pausing
experiences (Levitt, 2001b). In the present study,
coders achieved high interrater reliability for the
seven types of silences (Cohen’s k/0.80; 88%
agreement among the individual silence types, 97%
agreement among the silence categories [productive,
obstructive, neutral]). Kappa scores ‘‘greater than
0.75 or so represent excellent agreement beyond
chance’’ (Fleiss, 1981, p. 218).
To avoid coding simple speech dysfluencies,
pauses in this system are defined as silences of 3 s
duration or longer. This duration time initially was
identified by Levitt (2001) based on clients’ descrip-
tions of their experiences during silent moments in
psychotherapy. According to the descriptive statistics
of silences in psychiatric interviews reported by
Goldman-Eisler (1968), silences of 3 s or longer on
average accounted for only 10.2% of all silences and
so appeared to be unusual, supporting the finding
that at 3 s or longer there might be a meaningful
motivation for pauses other than simple dysfluency.
Ratings were determined by assessing contextual,
verbal, and paraverbal cues associated with each
silence category according to the guidelines deli-
neated in the PICS manual. The obstructive silences
category was composed of disengaged silences and
interactional silences. Disengaged silences were
coded when the client withdrew from a threatening
emotion, was avoiding an emerging emotionally
laden topic, was trying to regroup or control feelings,
or was shutting down emotionally (e.g., ‘‘I guess I
just felt really hurt. [5-s pause] But hey that’s in the
past now, right?’’). Interactional silences were iden-
tified as occurring when clients’ attention shifted to
the therapist instead of the topic at hand, as clients
sought approval or clarification of therapists’ mean-
ing or intent (e.g., ‘‘Well, I don’t know [5-s pause].
I-I don’t know exactly what we’re talking about,
I mean’’).
Productive silences referred to three types of silent
processes: emotional, expressive, and reflective.
Emotional silences were coded when clients were
feeling an emotion or were in the process of moving
into an emotional state (e.g., ‘‘I feel sort of sad
[4-s pause]. It’s a hollow feeling in my stomach’’).
Expressive silences were coded when clients were
searching for the correct word, phrase, or metaphor
with which to express themselves and best symbolize
their experiences (‘‘He’s sort of like [5-s pause] a
father, but one who isn’t angry’’). The reflective
silences were identified as silent moments of self-
analysis or self-examination in which clients turn
their attention on themselves in a sustained manner,
questioning an idea, experiencing heightened aware-
ness, or making mental connection or insights. In the
present study, a revision to the original PICS was
made (PICS-Revised; Levitt Frankel, 2004),
adding the differentiation of high reflective silences
that related to personally central issues (e.g., ‘‘I
wonder why I am struggling so much in that
relationship?’’ [5-s pause]) and low reflective pauses
that were related to incidental or superficial experi-
ences (e.g., ‘‘I wonder [3-s pause] why there was so
much traffic today.’’). High interrater reliability was
achieved on the differentiation between high and
low reflective silence in the present study (Cohen’s
k/0.799; 90.2% agreement). Subsequently, only
high reflective silences were included in the produc-
tive silences category.
The neutral silences category included mnemonic
pauses and associational silences. When clients
paused to recall events or items, this silent process
was coded a mnemonic pause (e.g., ‘‘What was that
teacher’s name?’’ [3-s pause]). Associational silences
were coded when a new idea emerged that was
disconnected from the ideas being expressed until
that point; the client had little left to say about a
topic or was trying to switch to another topic that
felt more pressing (e.g., ‘‘So that’s what happened.’’
[5-s pause] ‘‘But what I really want to talk about is
my mother’’).
Beck Depression Inventory (BDI; Beck, Ward,
Mendelson, Mock, Erbaugh, 1961). The BDI is
a 21-item self-report inventory of symptoms of
depression found to have testretest reliability
ranges between .48 and .86 and good content,
concurrent, and discriminant validity (Katz, Katz,
Shaw, 1999).
Symptom Checklist-90-Revised (SCL-90-R;
Derogatis, Rickels, Roch, 1976). The SCL-90-R
is a 90-item self-report measure of general symptom
distress found to have 1-week testretest reliability
coefficients ranging between .78 and .90 and inter-
nal consistency coefficient alphas ranging between
.77 and .90, as well as good predictive, construct,
convergent, and discriminant validity (Derogatis
Savitz, 1999).
Inventory of Interpersonal Problems (IIP; Horowitz,
Rosenberg, Baer, Ureño, Villaseñor, 1988). The
IIP is a 127-item self-report measure of distress
related to interpersonal relations that has demon-
strated a testretest reliability coefficient of .90
(Horowitz, et al., 1988).
Rosenberg Self-Esteem Inventory (RSEI; Rosenberg,
1965). A 10-item form of the RSEI (Bachman
O’Malley, 1977) was used as a measure of self-
Assessing psychotherapy silences 629

4. esteem. It has been found to have testretest
reliability coefficients ranging between .80 and .90
and internal consistency coefficients ranging be-
tween .89 and .94 (Bachman O’Malley, 1977).
Procedure
The three best and the three poorest outcome dyads
were selected from the client-centered psychother-
apy dyads in the York Depression I Project, a project
that compared 17 client-centered (CC) and 17
processexperiential (PE) treatments. This project
was designed to assess treatments of major depres-
sion (see Greenberg Watson, 1998). The three
best CC outcome dyads and the three poorest CC
outcome dyads then were identified (see Korman,
1998) and transcribed for further intensive narrative
(Angus, Levitt, Hardtke, 1999) and emotional
(Greenberg Angus, 2003) process analyses. Leslie
S. Greenberg and Lynne Angus supervised data
collection. The sample of best outcome and poorest
outcome CC therapy sessions were then intensively
analyzed to identify the silence processes that most
frequently occurred in the dyads associated with
positive client change within this one therapeutic
approach. The data from the two outcome groups
were analyzed in two ways. Overall findings were
obtained by aggregating across the therapy, and
trends over the course of the therapy sessions were
also examined. The former is useful for researchers
interested in understanding how silences function
globally in therapy. The latter is useful for research-
ers interested in the ways silence changes over time
as therapy progresses.
Once the complete census of silence data was
coded, three sampling strategies were executed: a
one-half random sampling procedure, a one-quarter
random sample, and a BME strategy. Each sampling
procedure was assessed on its relative accuracy
compared with the total census of all silence data.
Similar to the outcome group analyses, the data from
the three sampling strategies were analyzed in two
ways: over the course of the therapy sessions and
aggregated across the therapy. For both types of
examination, the analyses applied to the census were
repeated for each of the three samples drawn.
Consistent with the practice of epidemiological
researchers (Boyle, 1995), a sampling strategy
should yield results within 15% of the total census
results in order to be considered sufficiently accurate
for use. As such, a statistical test was not used to
compare the three sampling methods, and instead
each sampling strategy was compared with the
complete census to judge whether any provided
estimates within 15% of the census.
Designation of outcome groups. The outcome rank
for each dyad was determined by the investigators in
the York Depression I Project (Greenberg Watson,
1998; Korman, 1998) based on the four outcome
measures described. A residual change score for each
measure was calculated for each client. Residual
change scores provided an index of the amount of
change clients exhibited beyond what was statisti-
cally predicted by their initial test scores. These
scores represented the degree to which the clients’
outcome score differences (the pretreatment score
subtracted from the posttreatment score) deviated
from those predicted by the regression equation.
Clients’ scores were rank ordered from most change
to least change based on their residual change scores
for each of the four measures. Each client’s four
rankings were summed and the clients’ summed
rankings were then ordered from the lowest summed
ranking to the highest. The 3 clients with the lowest
summed rankings were classified as the best out-
comes and the 3 clients with the highest summed
rankings as the poorest. In terms of change scores,
the poor-outcome group demonstrated a mean
cumulative change score of /7.4, indicating sig-
nificantly less improvement than the good-outcome
group’s mean change score of /27.0267, F(1, 5)/
11.181, p/.029.
Silence coding. The silence coders were trained for
a period of 2 months by the original author of the
manual. Training included reviewing the manual
with the author, coding psychotherapy transcripts,
and reviewing the coding protocols to discuss
disagreements or misunderstandings. At the end of
the 2-month training, an interrater reliability analysis
of the two coders was calculated for their ratings of
the silences in five randomly selected psychotherapy
sessions from this database (which included a total of
167 silences from both good- and poor-outcome
dyads).The remaining 85 sessions then were ran-
domly assigned between the two coders. The length
of silences was measured during transcription and
noted with dashes (one dash per second silence).
Each coder read the transcript of each session while
listening to its corresponding audio recording. Dur-
ing the silence coding, the silence lengths were
verified. According to the 3-s minimum criterion,
1,503 silences were selected for coding. Questions or
uncertainties arising during coding were resolved by
reviewing the PICS manual.
After all of the sessions were coded for silence
type, the sessions were randomly assigned to the two
raters again, and the reflective silences were coded as
either high reflective or low reflective in accordance
with the PICS-R (Levitt Frankel, 2004). The first
six randomly selected sessions (which included a
630 Z. Frankel et al.

5. total of 51 reflective silences from both good- and
poor-outcome groups) were coded by both raters to
assess interrater reliability
Sampling strategies. For the one-half random
sampling strategy, half of the content of each session
was selected, starting at a point in the transcript
selected at random, determined by transcript line
number. For the one-quarter random sampling
strategy, one quarter of the content of each session
was selected, starting at a point in the transcript
selected at random, in the same fashion. The BME
strategy (3B-3M-3L) included the analysis of the
first three, middle three, and last three sessions of
each psychotherapy.
Results
An Assessment of Silences and Psychotherapy
Outcome
Frequency of silences aggregated across therapy. This
analysis assessed the statistical significance of the
differences between the two outcome groups in
terms of the frequency of total silence, using a one-
way analysis of covariance (ANCOVA), adjusting for
the number of coded therapy sessions (because of
the unequal number of sessions in each dyad). The
group mean predicted by the regression equation
when the covariate is at its mean level is referred to
as the estimated marginal mean (EMM). The poor-
outcome group (EMM/ 308.605, SE/ 20.93) had
a significantly higher frequency of total silence, F(1,
3)/ 15.212, p/ .030, h2
/0.835, than the good-
outcome group (EMM/ 192.395, SE/ 20.93).
Eta-square values were calculated as an index of
the effect size. As Rosenthal and Rosnow (1991)
point out, in analyses with only two groups (nu-
merator df/ 1), eta is ‘‘identical to r and may be
interpreted as r’’ (p. 351). Therefore, Rosenthal and
Rosnow (1991) explain, eta-square is a ‘‘correlation
index defined as the proportion of variation in the
dependent variable that is attributable to group
membership’’ (p. 317). The large effect size suggests
that the general silence behavior of the two outcome
groups differs substantially. Such a difference in style
of silence behavior is likely to obfuscate differences
in specific silence categories and types between the
outcome groups. One way to take the baseline silence
behavior into account would be to calculate a
proportion of the individual silence types to the total
silence. However, as Cohen, Cohen, West, and Aiken
(2003) warn, there is a potential danger of spurious
correlations associated with regression analyses of
proportions, which recommends instead the use of
ANCOVA to take the background behavior into
account. These considerations support using total
silence frequency as a covariate in further ANCO-
VAs, holding it constant while comparing other
silence variables (much like total caloric intake might
be held constant while assessing fat calorie intake).
Productive silence frequency. To test the hypothesis
that productive silence is positively related to psy-
chotherapy outcome, the productive silence fre-
quency was analyzed using a one-way ANCOVA,
adjusting for number of sessions and total silence
frequency. The large difference between outcome
groups approached statistical significance in the
predicted direction (EMMgood /118.509,
EMMpoor / 39.491, SE/ 14.520), F(1, 2)/
10.420, p/ .084. The very large effect size (h2
/
0.839) supports further research with larger samples
(Rosenthal Rosnow, 1991). The findings for the
individual productive silence types were all in the
predicted direction, and although they did not reach
statistical significance*high reflective (EMMgood /
69.124, EMMpoor / 25.209, SE/ 6.683), F(1, 2)/
12.529, p/ .071; expressive (EMMgood / 38.788,
EMMpoor / 1.879, SE/ 6.942), F(1, 2)/8.202,
p/ .103, h2
/0.804; and emotional (EMMgood /
10.597, EMMpoor / 4.403, SE/ 1.595), F(1, 2)/
4.377, p/ .172, h2
/0.686*the large effect sizes
support further study.
Obstructive silence frequency. To test the hypothesis
that obstructive silence is negatively related to
psychotherapy progress, we performed a one-way
ANCOVA, adjusting for the number of sessions
and total silence frequency. The difference, although
in the hypothesized direction and large, was not
significant (EMMgood /9.194, EMMpoor / 47.139,
SE/ 12.614), F(1, 2)/ 2.625, p/ .247. However,
the moderate effect size (h2
/0.568) supports
further study with larger samples. The findings for
the individual obstructive silences*disengaged
(EMMgood / /4.652, EMMpoor /22.985, SE/
1.818), F(1, 2)/ 67.055, p/ .015, h2
/0.971; and
interactional (EMMgood /13.846, EMMpoor /
24.154, SE/ 10.886), F(1, 2)/ 0.261, p/ .661,
h2
/0.115*suggest that disengaged silence is
highly related of poor outcome, because it had an
extremely high effect size and was significant at the
.05 alpha level, whereas the effect size for interac-
tional silence was small and not significant.
Neutral silence frequency. To assess the relationship
between outcome group membership and the neu-
tral silence category, we performed a one-way
ANCOVA, adjusting for the number of sessions
and total silence frequency. The difference found
Assessing psychotherapy silences 631

6. between the outcome groups was not significant
(EMMgood /4.388, EMMpoor / 12.612, SE/
3.035), F(1, 2)/ 2.130, p/ .282, h2
/0.515.
Silence Frequency Over the Course of Therapy
Sessions
The silence data were analyzed over the course of
therapy sessions to assess temporal patterns of
silences. To avoid losing data or imputing for missing
data, we used linear mixed-effects modeling (using
the MIXED procedure in SPSS, version 12). By
estimating both fixed and random effects, this
analysis accounts for the correlations among the
repeat observations. In addition, because linear
mixed-effects modeling uses the restricted maximum
likelihood estimation, it avoids the listwise deletion
that would be imposed by least-squares estimation.
All linear mixed-effects modeling analyses were
conducted with the covariance structure set as
compound symmetry.
Total silence frequency. An Outcome Group/Ses-
sion analysis was conducted to assess the difference
between the two outcome groups in total silence
frequency over the course of therapy. This analysis
found no significant effect for the interaction of
outcome group and session, F(16, 51.024)/1.507,
p/ .134, h2
/0.320 (denominator degrees of free-
dom are calculated using Satterthwaite’s, 1946,
approximation, which almost always results in non-
integer degrees of freedom). The analysis was
repeated without the interaction, and neither the
effect of outcome group (EMMgood /15.826, SE/
7.520, EMMpoor /19.852, SE/7.500), F(1,
3.974)/0.144, p/ .724, h2
/0.035, nor the effect
of session, F(17, 67.027)/0.885, p/ .594, h2
/
0.183, were found to be significant. This finding
indicates that the total silence behavior did not
change significantly over the course of therapy for
either outcome group.
Productive silence frequency. An Outcome Group/
Session analysis was conducted for the productive
silence frequency, adjusting for total silence fre-
quency, to assess the difference between the two
outcome groups over the course of therapy. This
analysis indicated that the Outcome Group/Ses-
sion interaction was not significant, F(16, 51.602)/
1.380, p/ .189, h2
/0.299. The analysis then was
conducted without the interaction, and the effect of
outcome was significant and in the predicted direc-
tion (EMMgood /6.749, SE/0.765, EMMpoor /
3.293, SE/0.745), F(1, 3.966)/10.531, p/ .032,
h2
/0.726, whereas the effect of session was not
significant, F(17, 67.318)/0.594, p/ .885, h2
/
0.130.
The findings for two constituent productive
silences*expressive (EMMgood /2.155, SE/
0.343, EMMpoor /0.548, SE/0.326), F(1,
3.636)/11.595, p/ .031, h2
/0.761, and high
reflective (EMMgood /3.876, SE/0.416,
EMMpoor /2.448, SE/0.392), F(1, 3.947)/
6.294, p/ .067; h2
/0.614*further support the
salience of expressive and high reflective silences;
the statistics on expressive silences reach significance
and those for high reflective silences approach
significance. In addition, the Session/Outcome
Group interaction for emotional silence, F(16,
51.646)/1.576, p/ .109, h2
/0.328, approached
significance, which points to differential patterns
of emotional silence over time, because the good-
outcome group exhibited more emotional silence
toward the beginning of therapy, whereas the poor-
outcome group exhibited more emotional silence
toward the end of therapy.
Obstructive silence frequency. An Outcome
Group/Session analysis was conducted for obstruc-
tive silence frequency, adjusting for total silence
frequency, to assess the difference between the
two outcome groups over the course of therapy.
The Outcome Group/Session interaction, F(16,
51.039)/0.669, p/ .810, h2
/0.173, was not sta-
tistically significant. The analysis then was con-
ducted without the interaction. The effect of
outcome group (EMMgood /1.355, SE/0.477,
EMMpoor /2.290, SE/0.468), F(1, 3.858)/
1.969, p/ .236, h2
/0.337, and the effect of ses-
sion, F(17, 67.068)/0.811, p/ .675, h2
/0.170,
were not statistically significant. The findings for the
constituent obstructive silences*disengaged
(EMMgood /0.233, SE/0.256, EMMpoor/0.939,
SE/0.252), F(1, 3.877)/3.879, p/ .122, h2
/
0.500, and interactional (EMMgood /1.127, SE/
0.306, EMMpoor /1.340, SE/0.293), F(1,
3.790)/0.255, p/ .641, h2
/0.063*followed the
same pattern as the aggregated silence findings;
disengaged silence approached significance and
interactional silence did not.
Neutral silence frequency. An Outcome Group/
Session analysis was conducted for neutral silence
frequency, adjusting for total silence frequency, to
assess the difference between the two outcome
groups over the course of therapy. The Outcome
Group/Session interaction, F(16, 51.386)/0.702,
p/ .779, h2
/0.179, was not statistically significant.
The analysis then was conducted without the inter-
action. The effects of outcome group (EMMgood /
0.663, SE/0.158, EMMpoor /0.511, SE/0.151),
632 Z. Frankel et al.

7. F(1, 3.498)/0.483, p/ .530, h2
/0.121, and ses-
sion, F(17, 67.334)/0.803, p/ .684, h2
/0.168,
were not statistically significant.
Sampling Strategies
Silence frequency aggregated across therapy sessions.
The size-adjusted descriptive statistics of the total,
productive, and obstructive silence frequencies from
the three sampling strategies and the total census are
presented in Table I. The findings indicate that the
one-half random sampling strategy provided the best
estimates of silences aggregated across psychother-
apy sessions. All of the one-half random sample
estimates for outcome group silences aggregated
across sessions (total silences, productive silence,
and obstructive silences) were within 8% of the
values from the total census data compared with
differences of as much as 19% in the one-quarter
random sample and 24% in the 3B-3M-3L sample.
These findings demonstrate that the amount of
sampling error was considerably less when using
the one-half random sampling strategy compared
with the other strategies.
Silence frequency over the course of therapy sessions.
The one-half random sample fared better than the
other sampling strategies in its estimates of silences
over the course of therapy and on average provided
session estimates of total silence that were close to the
15% criteria typically used in epidemiological studies.
Even so, the average error of the session estimates of
productive and obstructive silences were as high as
38%, representing significant sampling error. This
finding suggests that researchers who are interested in
studying individual sessions may choose to use the
half-session random sampling technique, but their
cost in terms of validity would be high if they were
seeking to study the isolated effects of obstructive
or productive silences instead of total silence.
Discussion
Outcome Group Differences in Silence
Frequency
The findings comparing good and poor dyads in
their silence frequencies aggregated across psy-
chotherapy demonstrated very promising effect sizes
in the predicted directions that approached statistical
significance for one of the productive silences, high
reflective, and for one of the obstructive silences,
disengaged silence. The findings also strongly sug-
gest further research of the two other productive
silences: expressive silence and emotional silence.
The findings for silence frequencies over the course
of psychotherapy sessions using a repeated measure
design practically mirrored the aggregated frequency
findings. These results provide additional quantita-
tive support for Levitt’s (1998b, 2001a, 2001b,
2002) typology of psychotherapy silences and war-
rant continued research on psychotherapy silences
with larger samples using the PICS.
In this study, silences are understood as markers of
internal processes, which are important because they
suggest times in which clients’ internal experiences
are so compelling that they disrupt the therapeutic
interaction. These findings are of interest not be-
cause they represent the lack of speech but because
they suggest internal experiences that unfold for
clients within the discourse gaps. As such, the
present findings are consistent with client-centered
psychotherapy’s theory of change, in which change
results from the accessing of genuine, albeit some-
times anxiety-provoking, feelings, thoughts, and
experiences and lend support to its model of change
(Rogers, 1951, 1961). For example, the productive
and obstructive silence findings indicate that avoid-
ing emotional experiences was negatively associated
with psychotherapy outcome, whereas focusing at-
tention on pertinent issues and seeking new ways to
symbolize experience was positively associated with
psychotherapy outcome.
However, emotional silence frequency differences
between the outcome groups did not come as close
to meeting statistical significance as the other
productive silences did. Even though the good-
outcome group averaged more than twice as many
emotional silences as the poor-outcome group
(10.597/4.403/2.4), the frequency of these silences
was found to be very low in general, averaging less
than one per session, even among the good-outcome
group. This finding is surprising given that all of the
6 clients in the current study were treated with
client-centered psychotherapy, which prizes emo-
tional empathy as a key change mechanism (Rogers,
1975). The answer seems to lie in the analyses of
silences over the course of therapy, where a
Session/Outcome Group interaction was found
for emotional silence frequency, approaching signifi-
cance. This finding suggests that good-outcome
therapies tended to exhibit higher frequencies of
emotional silence during the first half of therapy,
after which they decrease in frequency. The poor-
outcome therapies exhibit the exact opposite pat-
tern, beginning therapy with very low frequencies of
emotional silence which then increase toward the
end of therapy. Based on the model of change
proposed by client-centered psychotherapy (Rogers,
1951), a pattern of earlier emotional processing
would indeed be expected to predict better outcome
(within a limited number of sessions), because
Assessing psychotherapy silences 633

8. Table I. Size-Adjusted Descriptive Statistics and Percentage Differences of Total, Productive, and Obstructive Silences by Sampling Strategy.
3B-3M-3L One-quarter random One-half random Total census
Variable F M SD %^ F M SD %^ F M SD %^ F M SD
Total silences
Good 753.4 251.1 130.6 19.000 580 193.3 43.8 8.37 640 213.3 85.3 1.100 633 211.0 171.6
Poor 793.4 264.4 93.9 8.800 992 330.6 46.6 14.00 862 287.3 67.3 0.919 870 290.0 109.2
Cumulative 1547.0 257.8 101.8 0.266 1572 262.0 44.6 4.59 1502 250.3 71.6 0.000 1503 250.5 135.7
Productive silences
Good 301.7 100.5 43.3 15.500 216 72 15.7 17.20 258 86.0 28.8 1.140 261 87.0 60.8
Poor 143.3 47.7 14.4 24.100 228 76 10.0 20.60 186 62.0 13.0 1.580 189 63.0 19.9
Cumulative 445.0 74.1 33.7 1.110 444 74 11.8 1.33 444 74.0 21.1 1.330 450 75.0 42.5
Obstructive silences
Good 73.3 24.4 13.6 35.700 60 20 4.3 11.10 62 20.6 8.7 14.800 54 18.0 15.1
Poor 128.3 42.7 17.1 11.500 132 44 8.7 14.70 114 38.0 15.1 0.869 115 38.3 24.5
Cumulative 201.7 33.6 15.1 19.300 192 32 6.9 13.60 176 29.3 12.0 4.140 169 28.1 21.3
Note. 3B-3M-3L/first three, middle three, and last three sessions of each psychotherapy; good: n/3; poor: n/3; cumulative: n/6.
634
Z.
Frankel
et
al.

9. ‘‘emotion accompanies and in general facilitates
such goal-directed behavior’’ (p. 492). These find-
ings may suggest that, toward the end of therapy,
poor-outcome clients are reaching the place that
good-outcome clients were at the outset of treatment
and might benefit from longer term treatment.
Overall, the present findings suggest a general
guideline that it can be helpful for therapists to
stimulate emotional, reflective, and expressive si-
lences and that they hesitate to intervene during a
silence unless the silence appears disengaged. Such
an intervention during a productive silence may
interrupt clients’ introspective processes, working
to fetter, instead of facilitate, the progress of
psychotherapy.
Sampling Strategies: An Empirical Solution for
the Sampling Problem
In the present study, three sampling strategies were
assessed to determine the strategy that most closely
resembled the complete census data. Of the 3B-3M-
3L, one-quarter random sampling, and one-half
random sampling strategies, the one-half random
sample was found to render the most accurate
estimate when researchers are studying silences
across an entire therapy, providing estimates within
8% of the total census data for both outcome groups.
It also appeared to be an adequate estimate of the
total census data in its estimates of the silence
frequency for the study of individual sessions over
the course of therapy, at least for total silence. These
findings provide an empirical basis for using a one-
half random sampling strategy in future studies of
silences, while warning of the potentially substantial
error introduced by other sampling strategies.
In addition, the sampling strategy findings provide
a corrective lens with which to view past silence
research conducted with previously untested sam-
pling strategies. For instance, early research done by
Cook (1964) and Staples and Sloane (1976) used
sampling methods such as randomly selecting 2-min
segments from the second and second-to-last ses-
sions or randomly selecting three 4-min segments of
first sessions. Based on the findings of the present
study, such sampling methods, far from sampling
even one quarter of therapy, can be expected to
introduce considerable error, making it difficult to
compare studies and interpret their findings. The
findings of the present study make the PICS the only
psychotherapy process measure to have categories
developed from an empirical analysis of clients’
psychotherapy experiences and exhibited behaviors,
reports of strong interrater and client-rater reliability
(Levitt, 1998b), and an empirically supported sam-
pling strategy.
Study Strengths and Limitations
This study provides a rare look into the patterns of
silences and their underlying processes in good- and
poor-outcome cases of a complete course of client-
centered psychotherapy. Although some of the
probability values in this research only approach
significance, the large effect sizes and the consistency
with which the findings match the hypothesized
direction provide support for the PICS model of
clients’ silences in psychotherapy. The conceptuali-
zation of silent processes represented in the PICS
now has received support from both qualitative and
quantitative studies. Research programs that incor-
porate mixed methods are often thought to enhance
claims because they produce evidence using multiple
analytic strategies (e.g., Hanson, Creswell, Plano
Clark, Petska, Creswell, 2005).
As a result of the small sample size necessary for
this intensive analysis, power was necessarily limited.
However, because of the rigorous statistical analyses
used to analyze the process measure data, controlling
for baseline silence behavior, number of sessions,
and potential correlations within session observa-
tions, we can have greater confidence in the findings.
In addition, to help future researchers increase their
sample sizes, an empirically based sampling proce-
dure was developed and introduced, which is an
advancement in process measure research.
Although the raters achieved an excellent level of
interrater agreement on a randomly selected set of
sessions, the sampling method developed in this
current study may lead to the further reduction of
coding errors in future studies. By allowing research-
ers to capitalize on the smaller sample size, this
method could enable the use of a number of
different raters, who then could reach consensus
when disagreements arose, as recommended by Hill
et al. (2005).
Because of the time-intensive nature of process
coding and the large number of silences coded, the
ability to generalize from the findings of the present
study is limited by its focus on six dyads of client-
centered treatment of depression: the three best and
the three poorest outcome dyads. The ability to
project the types of silence processes exhibited by
other client and therapist populations as well as
intermediate-level outcome dyads is particularly
circumscribed.
Implications
The results of the present study suggest that silences
come in a variety of types that can be meaningfully
and reliably differentiated and used to assess clients’
therapy processes during psychotherapy sessions. In
the present study, the PICS was able to reliably
Assessing psychotherapy silences 635

10. identify silence processes and point out subtle
differences between good-outcome and poor-out-
come psychotherapies. Because of the theory-neutral
processes that the silence types indicate, such as
emotional experiencing, withdrawal, and reflection,
it seems that therapists of all orientations could use
research based on the empirically derived PICS
categories to enhance clinical judgment and facilitate
psychotherapeutic decision making, while research-
ers may find the measure and its empirically
supported sampling strategy to be useful in the
assessment of psychotherapy process. The continua-
tion of psychotherapy silence research promises to
equip therapists with increased sensitivity to aid in
the negotiation of silences within the therapy hour
and open a window into clients’ internal experiences.
Acknowledgements
We would like to acknowledge and express our
gratitude to Dr. Robert A. Neimeyer, Dr. Adam
Anderson, and Karina Raina for their help with this
project.
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Zusammenfassung
Die Einschätzung von Pausen im
Psychotherapie-Dialog: Die Entwicklung eines
Kategoriensystems und eine empirisch abgeleitete
Strategie zur Erhebung von Stichproben
Pausen, in den vom Ergebnis her drei besten und drei
schlechtesten Dyaden klientenzentrierter Psychotherapie
im Depressionsprojekt von York wurden mit Hilfe des
Pausenkategorisierungsystems-Fragebogens (Pausing In-
ventory Categorization System [PICS]) codiert. Über 90
Sitzungen hinweg wurden 1503 Pausen von drei Sekunden
oder länger codiert. In Übereinstimmung mit den von
PICS abgeleiteten Hypothesen, zeigten Dyaden mit guten
Ergebnissen mehr emotionales, expressives und in hohem
Maße reflektierendes Schweigen und weniger interaktive
Pausen oder Schweigen nach niedrigem Engagement als
Dyaden mit schlechteren Ergebnissen. Die Strategie zur
Bildung von Stichproben wurde mit dem gesamten Da-
tenmaterial zur Pausenerhebung verglichen: Die erste
Methode bezog sich auf die ersten drei, die mittleren
drei und die letzten drei Sitzungen, während die beiden
anderen Methoden dem Zufall nach entweder ein Viertel
oder die Hälfte aller Sitzungen erfassten. Die Erfassung
der Hälfte jeder Sitzung erbrachte Ergebnisse, die der
Erfassung durch das Gesamtmaterial am nächsten kamen.
PICS kann nun als ein Prozessmaß mit einer theoretischen
Grundlage sowohl bei qualitativen als auch quantitativen
Untersuchungen angesehen werden bezüglich der Erfas-
sung von Klienten und hinsichtlich der Ergebnisdifferen-
zierung von Gruppen, mit einer hohen Klienten- Rater-
und Interrater-Übereinstimmung und einer empirisch
getesteten Methode zur Bildung von Datenstichproben.
Résumé
Evaluer des processus silencieux en psychothérapie :
un système de catégorisation et une stratégie
d’échantillonnage empiriquement dérivés
Les silences dans les 3 dyades au résultat le meilleur et les
3 au résultat le plus modeste de psychothérapies centrées
sur le client faisant partie du Projet de Dépression I de
York étaient cotés à l’aide du Système de Catégorisation de
l’Inventaire des Pauses (PICS). A travers 90 séances, 1,503
silences de 3 sec ou plus étaient cotés. En accord avec les
hypothèses proposées par le PICS, les dyades favorables
ont montré des silences plus émotionnels, plus expressifs et
hautement réflexifs, et moins de silences désengagés et
interactionnels que les dyades à résultat modeste. Trois
stratégies d’échantillonnage étaient comparées avec le
compte total des données de silence : 1 échantillonnait
les 3 premières séances, les 3 du milieu et les 3 dernières,
alors que les deux autres échantillonnaient au hasard soit
un quart soit la moitié de chaque séance. L’échantillon-
nage par la moitié aboutissait au résultats les plus proche
du compte total. Le PICS peut maintenant être situé
comme une mesure de processus avec une base concep-
tuelle dans la recherche qualitative sur l’expérience des
clients, avec une fidélité client juge et inter juge haute,
une validation par la recherche quantitative sur la dif-
férentiation des groupes d’efficacité, ainsi qu’avec une
méthode d’échantillonnage empiriquement testée.
Resumen
Evaluación de los procesos silenciosos en
psicoterapia: un sistema de categorización y una
estrategia de muestreo empı́ricamente obtenicas
Se codificaron los silencios de los 3 mejores y los 3 peores
resultados de las dı́adas de psicoterapia centrada en el
cliente en el Proyecto York de Depresión I por medio del
Inventario del Sistema de categorizaciónde Pausas (PICS).
Durante 90 sesiones, se codificaron 1.503 silencios de 3
segundos o más largas. De acuerdo con las hipótesis
propuestas por el PICS, los Buenos resultados de las
dı́adas mostraron silencios más emocionales, expresivos y
altamente reflexivos y menores desconexiones y silencios
interaccionales que las dı́adas de resultados pobres. Se
Assessing psychotherapy silences 637

12. compararon tres muestras de estrategias con el ceso
complete de datos de silencio: 1 tomó muestras de las
primeras 3, las 3 del medio y las últimas 3 sesiones,
mientras que las otras 2 tomaron muestras randomizadas
de un cuarto o de la mitad de cada session. La estrategia de
muestreo de media randomizada dio resultados más
cercanos al censo complete. El PICS puede situarse ahora
como un proceso de medición con una base conceptual en
investigación cualitativa sobre la experiencia de los clients,
altos evaluadores de cliente (high client_/rater) y confiabi-
lidad entre juices, validación por medio de investigación
cuantitativa en el resultado de diferenciación grupal y un
método de muestreo testeado empı́ricamente.
Resumo
Avaliando os processos silenciosos em psicoterapia:
Um sistema de categorização empiricamente
derivado e uma estratégia de amostragem
Foram cotados os silêncios das 3 melhores e 3 piores
dı́ades de resultados terapêuticos de psicoterapia centrada
no cliente do Projecto da Depressão de York I usando o
Sistema de Categorização do Inventário de Pausas (PICS).
Ao longo de 90 sessões, foram cotadas 1503 silêncios de 3
ou mais segundos. De acordo com a hipótese proposta pela
PICS, as dı́ades de resultado terapêutico positivo exibiam
silêncios mais emocionais, expressivos e altamente reflex-
ivos e menos silêncios de desinteresse e interaccionais que
as dı́ades com resultados mais pobres. Foram comparadas
três estratégias de amostragem com o censo completo dos
dados de silêncios recolhidos: Um seleccionou as primeiras
3 sessões, 3 sessões intermédias e as 3 sessões finais;
enquanto que as outras duas amostraram aleatoriamente
ou um quarto ou metade de cada sessão. A estratégia de
amostrar aleatoriamente metade das sessões forneceu os
resultados mais aproximados aos do censo completo. O
PICS pode agora ser posicionado como uma medida de
processo com base conceptual na investigação qualitativa
da experiência do cliente, elevada fidelidade cliente-juiz e
interjuı́zes, validação através da investigação quantitativa
na diferenciação dos resultados de grupo, e como um
método de amostragem empiricamente testado.
Sommario
Valutare i processi silenti nella psicoterapia: sistema
di categorizzazione empiricamente derivata e stra-
tegia di campionamento
Sono stati valutati nel York Depression Project i silenzi
relativi alle 3 migliori ed alle 3 più povere diadi di
psicoterapie centrate sul cliente. I silenzi sono stati
codificati usando il Pausing Inventory Categorization
System (PICS). Attraverso 90 sedute, sono stati codificati
1.503 silenzi di 3 secondi o più lunghi. In conformità con
le ipotesi proposte dal PICS, le diadi con buoni outcome
hanno esibito i silenzi riflettenti più emozioni, più espres-
sivi ed elevata riflessione e impegnato pochi silenzi inter-
relazionali rispetto le altre diadi. Sono state paragonate tre
strategie di campionamento al censimento completo dei
dati relativi al silenzio: la prima strategia ha provato le
prime 3, le 3 di mezzo e le ultime 3 sessioni, mentre le altre
2 strategie hanno provato a caso un quarto o una metà di
ogni sessione. La strategia della metà casuale del campione
ha fornito i risultati più vicini al censimento completo. Il
PICS ora può essere ritenuto come una misura per una
base concettuale nella ricerca qualitativa dell’esperienza
sui clienti, ad alta affidabilità del interrater reliability
clienti/valutatori, validato attraverso la ricerca quantitativa
fondata sugli outcome del gruppo, e empiricamente testato
con un metodo di campionamento.
638 Z. Frankel et al.