Therapists-in-Training Experiences of Working With Transfer Cl.docx

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:
[email protected]
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:[email protected]
mailto:[email protected]
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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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

Current Therapist’s personal qualities G (11)
Current Therapist’s technical skills T (9)
Current Therapist’s personal qualities G (12)
Current Therapist’s lack of technical skills T (10)
Transferred client 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)
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
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)
Failed to provide guidance about how to work with transfer
clients T (7)
Characteristics of training clinic

Clinic policies and procedures T (10)
Institutional aspects of clinic T (10)
Documentation requirements T (9)
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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e
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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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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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T
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so
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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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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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e
of

its
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lie
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bl
is
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rs
.
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hi
s
ar
tic
le
is
in
te
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ed
so
le
ly

fo
r
th
e
pe
rs
on
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e
of
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in
di
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du
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d
is
no

t
to
be
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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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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.
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analysis of
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Bowlby, J. (1969). Attachment and loss: Vol. 1: Attachment.
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Boyer, S. P., & Hoffman, M. A. (1993). Counselor affective
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Clark, P., Robertson, J. M., Keen, R., & Cole, C. (2011).
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(2002). An investigation of European American therapists’
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Hill, C. E., Knox, S., & Hess, S. A. (2012). Qualitative meta-
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Liner, A., . . . Salmen, K. (2015). Novice therapist attachment
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Messer, S., & Wampold, B. (2002). Let’s face facts: Common
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Penn, L. (1990). When the therapist must leave: Forced
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counseling. American Psychologist, 53, 440–448.
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14, 107–113. http://dx.doi.org/10.1007/BF00582175

Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy
debate:
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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/10.1177/0011000002305007

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/10.1037/a0022140
http://dx.doi.org/10.1037/a0022140
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http://dx.doi.org/10.1521/pdps.2013.41.4.575
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http://dx.doi.org/10.1037/0003-066X.53.4.440
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http://dx.doi.org/10.1007/BF00757618
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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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Therapists-in-Training Experiences of Working With Transfer
Clients: One Relationship Terminates ...The Impact of Transfers
on Clients: Empirical FindingsThe Impact of Transfers on
Therapists-in-Training: Empirical FindingsPurpose of the
Current StudyMethodData Set and Description of Clinics and
Client Population ServedTrainee
ParticipantsMeasuresDemographic formInterview
protocolProcedureSelection of participantsInterviewData
analysisResultsPrior Therapist Characteristics That Influenced
the Transfer ProcessFacilitating characteristicsHindering
characteristicsCharacteristics of Current Therapist That
Influenced the Transfer ProcessFacilitating
characteristicsHindering characteristicsClient Characteristics
That Influenced the Transfer ProcessFacilitating
characteristicsHindering characteristicsImpact of the Supervisor

on TransferFacilitating characteristicsHindering
characteristicsCharacteristics of the Training ClinicFacilitating
characteristicsHindering characteristicsInfluence of Transfer on
Therapist ParticipantsInfluence of Transfer on the Transfer
ClientDifference Between Transfer and Nontransfer
ClientsRecommendations for Transfers in Training
ClinicsDiscussionInfluence of Transferring TherapistsInfluence
of Transferred-to Therapists on TransfersThe Influence of
Client Characteristics on the Transfer ProcessThe Impact of
Transfers on Therapist Sense of IdentityThe Impact of Transfer
on ClientsTherapists’ Recommendations for Transfers in
Training ClinicsDifferences Between the Two ClinicsStrengths
and LimitationsImplications for Theory and
PracticeImplications for Training and
ResearchReferencesAppendix Transfer Study Interview Protocol
Answer following question: BE SURE TO QUOTE THE
QUESTION or you will lose points (type out the complete
question or cut and paste)!! Word count
600-700 total
· “Tell me about a time when you had to go above and beyond
the call of duty in order to get a job done. WHAT MADE IT
“ABOVE AND BEYOND”?
Use the STAR (Situation Task Action Result) method in your
presentation. Make sure the ACTION part of your narrative is
about half of the total answer
Plus, answer any one of the following questions (be sure to
quote or cut and paste the question):
· Describe a situation in which you were able to use persuasion
to successfully convince someone to see things your way?
WHAT WAS IMPORTANT TO YOUR SUCCESS?
· Tell me about a time when you went above and beyond the call
of duty in order to get a job done. WHAT MADE IT “ABOVE
AND BEYOND”?
· Tell of the most difficult customer service experience that you

have ever had to handle -- perhaps an angry or irate customer.
Be specific and tell what you did. WHAT SKILLS DID YOU
DISPLAY? What was the outcome?
· Tell me about a time when you had to deal with an ambiguous
situation where there was no clear direction as to what you were
supposed to do, and you had to figure things out o your own,
maybe not even knowing if there was a right choice.
· Recall a time from your work experience when your manager
or supervisor was unavailable and a problem arose and you had
to deal with it on your own. What was the nature of the
problem? How did you handle that situation?
· Recall a time when you had to bounce back from failure or
disappointment. How did you do it? WHAT DID YOU LEARN?
· Tell me about a time when you came up with an idea to
enhance your employer’s business operation and implemented
it.

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