A journey to client and therapist mutuality in person-centered psychotherapy: a case study

This aim of this case study was to build theory on the development of client–therapist mutuality in person-centered psychotherapy. A case study focusing on a 42-year-old female client who had presented for therapy following trauma within interpersonal relationships has been used. A reflective, theory-building, case study method was adopted that used data gathered from verbatim session notes and research interviews between the therapist (first author) and research supervisor (second author). Three primary therapeutic processes that contributed to the development of mutuality are discussed. First, the development of mutual empathy in the relationship; second, strategies for disconnection and staying out of relationship are identified. Third, client agency and mutuality is explored. In conclusion the study proposes that mutuality is a key construct within person-centered psychotherapy and develops as a natural consequence of the presence of Rogers’ therapeutic conditions.


Introduction
The concept of mutuality has been posited to be a key construct in person-centered psychotherapy. The term mutuality refers to the bidirectional, reciprocal, co-created, client-therapist experience of the therapeutic conditions of unconditional positive regard, empathic understanding and congruence (Murphy, 2010;Murphy, Cramer, & Joseph, 2012). Mutuality in the person-centered therapeutic relationship involves both client and therapist encountering each other where both experience congruently, to varying degree, unconditional acceptance and empathy. In meeting each other mutually, the therapist's focus remains centered on the client's moment-to-moment experiencing in the session. Thus the therapist relates to the client in a Thou-I stance (Schmid, 2006). Mutuality implies that in these moments the relationship is experienced the same on both sides; that is, both client and therapist experience has equal validity (Rogers, 1960, cited in Anderson & Cissna, 1997, and that each perceives and experiences Rogers's therapeutic conditions (Murphy et al., 2012) both in and towards the other.
Following from Rogers's (1959) proposed process-outcome model of person-centered therapy there has been a growing recognition that the structure of the therapeutic relationship is bi-directional (Knox, Murphy, Wiggins, & Cooper, 2013;Mearns & Cooper, 2005). However, research on the process and development of mutuality has only recently come to the fore. The current case study examines the theory of mutuality and its development and proposes three main processes as contributory factors in the development of mutuality; these are mutual empathy in the therapeutic relationship, strategies for disconnection/staying out of relationship and, client agency in mutuality. Each process illuminates and extends the theoretical understanding regarding the development of mutuality.

Mutuality and client progress
A recent study that focused on the presence of the mutual experience of the therapeutic conditions considered the association between mutuality and client progress (Murphy, 2010;Murphy & Cramer, 2014). The finding provided support for a mutuality hypothesis. The mutuality hypothesis suggests an association between clients' progress in therapy and the mutual experience of congruence, unconditional positive regard and empathic understanding. The study asked therapists and clients, using items from the Barrett-Lennard Relationship Inventory (Barrett-Lennard, 1962), to rate their own and their perception of others' experience of the therapeutic conditions. Findings indicated the perceived mutuality of relationship conditions predicted client progress during the first three psychotherapy sessions (Murphy & Cramer, 2014). Whilst such studies support the proposal that mutuality is related to progress they are yet to shed light on how mutuality develops within the therapeutic relationship.

Mutuality as a process
The potential for mutuality to occur within the therapeutic relationship has been questioned (Aron, 1996;Proctor, 2010). Critiques are based on the argument that an inherent inequity in the therapeutic relationship prevents mutuality from developing. Similarly, others have suggested mutuality theory fails to recognize the inherent conflict that can occur in relationships; suggesting instead that theories of mutuality account for only those relationships that are going well; or even, that mutuality provides medicine for the therapist (Bazzano, 2014). These are two important critiques of the concept of mutuality. However, they are rooted in a view of the therapeutic relationship from the outside. Neither considers the experience of mutuality from inside the therapy relationship. From the outside, the therapy relationship is always unequal. Role power is an inescapable truth of psychotherapy. However, being equal must not be conflated with being mutual, at least not in the way that mutuality is defined in person-centered psychotherapy; relationships that are unequal from the outside (such as through differences in role power) can be experienced as mutual from the inside. This point was discussed by Rogers in 1957(as cited in Anderson & Cissna, 1997 in dialogue with Buber, when he suggested that although differences in power are always present, when the relationship is considered from the inside it is possible to experience a mutual encounter. Mutuality refers to the process and development of the relationship conditions. It is not intended to be a descriptive term to sum up the equality of a relationship. Mutuality is a relational process that develops through the struggle and conflict that can exist within therapeutic work, the mundane, uneventful periods of therapy, as well as dynamically challenging and intense anxiety-invoking moments. Every moment in the therapy is an opportunity for mutuality to develop. To position mutuality as a state, a goal, or preferential type of relating is also to miss the point. It is through the struggle of encounter that mutuality emerges. Mutuality develops because of these experiences not instead of them. Mutual experiencing of Rogers's relationship conditions is the naturally occurring process-outcome of the therapy relationship. To position this as "medicine" for the therapist negates the client's potential to be both a patient and agent (Rennie, 1998).

Aim
Currently, theory suggests that mutual experiences of the therapeutic conditions are related to client progress. The aim of this case study was to develop theory on the process and development of mutuality through an example in which there were difficulties for both the client and therapist in being in the therapy relationship.

Case study research design
Case study is a useful method for both testing and building theory (Stiles, 2007). There is, however, an inevitable tradeoff between the limitations of the specific context of a case study and its ability to deal sensitively with the complexity of a single therapeutic relationship. Case study offers the opportunity to look at 'specific factors that may lead to some clients reporting better outcomes than others' (McLeod & Elliott, 2011, p. 3). They are also relevant for and can enhance our understanding of the idiosyncratic features of practice from real world settings by adding to the body of evidence-based practice for a specific field of inquiry or practice. Although single case study research does not enable wide generalizable claims for theory or practice, case study research does offer a chance to develop insight into what happens in therapy, with regards to both therapist and client. This enables theories to be permeated (Stiles, 2005) with new emerging concepts and constructs that can add to the depth with which theories are understood.
This is a theory-building case study that adopted a collaborative reflective approach. So as not to be limited by the therapist's lone account of the relationship, and to provide rigorous testing of the propositions in developing the theory, the client contributed feedback to an earlier draft. As a theory-building case study the aim is to both further support the concept of mutuality and highlight new theoretical developments that advance theoretical understanding in the area.

Data collection
In keeping with theory-building case studies data was gathered from multiple sources (Stiles, 2007) based on the work with one client over 13 sessions of person-centered psychotherapy. First, close to verbatim session notes were made by the first author who was also the therapist. Session notes were written immediately after the first eight sessions had ended; a practice encouraged for facilitating processing the session in supervision. Second, five sessions were also audio recorded and later transcribed. Third, three interviews were conducted specifically for the research project and involved the second author interviewing the first author about her experiences in therapy. Notes were made during these interviews that were later used to inform the interpretation of therapeutic process. Fourth, the first author/therapist and the client reviewed the findings of a draft version of the case study and discussed them together. The aim was to form a collaborative reflective process informing the development of the case study. The original case study was submitted in partial fulfillment for the degree of Master of Art in Counselling Practice.

Data analysis
The first author read and re-read the session notes and listened to the audio recording from therapy sessions to become immersed in and review the data that had been collected. Through a process of immersion in the data and thoughtful reflection on the process of therapy several themes were identified. The themes were taken and used as the basis for further reflection in the research interviews and were considered alongside the existing theoretical knowledge in the field of mutuality. The research interviews were non-directive and unstructured allowing for new theoretical ideas to emerge and permeate existing theory. The content focused on the following themes; making an impact, mutual empathy, mutual connection/disconnection, mutuality and self-disclosure, agency in mutuality. Themes formed the basis of the initial draft that was presented to the client. The client provided verbal feedback to the first author. The feedback was used as a source of triangulation for the themes proposed, or as Stiles (2005, p. 58) suggests, provide a source of "experiential correspondence theory of truth". Following discussion between the client and first author the themes for self-disclosure and agency were revised and subsequently merged together to form the theme client agency in mutuality making the final three themes; (1) Developing mutual empathy, (2) Strategies for disconnection, (3) Client agency in mutuality. Mutual empathy is a theme that has been central to the existing theory of mutuality but strategies for disconnection and client agency in mutuality were new areas that were illuminated through the current case study.

Ethical issues
Ethical clearance for the study was granted through the University department in which the study took place. The client, therapist and second author were all co-researchers in the project. The client is not named as an author to respect anonymity and maintain confidentiality; it is recognized that this is potentially compromised by the degree to which the context, the client's and therapist's life stories are revealed. The client provided signed informed consent prior to the case study.
In researching the topic of mutuality we considered the client's inclusion in the research process as a primary component. Whilst it is understood this might not always be possible, it was considered appropriate and ethical to include the client as a response to the client's expressed interest to be involved. The client, in giving consent to be the focus of a case study, also expressed interest in being a co-researcher. We considered and came to the decision using the following principles; (1) Researching mutuality is a process of researching with clients and not on clients.
(2) Clients are capable of making informed choices about whether they want to be involved as co-researchers. (3) Clients have a right to be included in research that concerns them.
(4) It is ethical and responsible to include clients as co-researchers at a level that gives them input and influence over the points being presented and the research questions being asked.

Participants and context for therapy
The therapist and first author works in a student counseling service. Qualified to diploma level with four years of practice experience the therapist was studying for a Master's Degree in person-centered therapy. The client had self-referred to the counselling service. Therapy started for six sessions and then was stopped for the summer recess. Therapy resumed the following academic year in the autumn term for a further 12 sessions. The therapist selected the case for study due to feeling a strong connection with the client but also the client's strategies for disconnection had been identified as of potential interest for further study. The second author acted as the research supervisor and facilitated the reflective research interviews. The second author is a psychologist specializing in person-centered psychotherapy and was the tutor of the first author during her diploma course. The first and the second author met on three occasions to discuss and reflect on the research data.
The client is referred to throughout as Mrs Kay. Personal details in this section were changed to protect the anonymity of the people directly involved and could be implicated through the client's narrative (Sikes, 2010). The client presented to therapy seeking help adjusting to a series of traumatic life events. The client described the following; difficulty in developing intimate close personal relationships, a general lack of positive relationships, and the relationship with her teenage son being stuck in a pattern of persistent conflict. Over the course of the first five sessions Mrs Kay described a traumatic life history including having been subjected to domestic violence in two previous marriages, experiencing a miscarriage and an ectopic pregnancy. Mrs Kay also reported a particularly traumatic event, involving having been sexually assaulted by a family member at the age of 13. Further disclosures from Mrs Kay expressed her preference for finding anonymous sex as more "tolerable" than having a close loving partner, being repulsed by her own body, and "shuddering" at the thought of being given a hug. These factors all contributed to Mrs Kay's difficulty developing close interpersonal relationships.
In addition the therapist reported that Mrs Kay had limited reflexive awareness of how other people perceived her (Rennie, 1998). For example, Mrs Kay reported that if she had been "nice or nasty" to people she seemed unable to articulate the other person's response towards her. The thought of others having an opinion about her, whether favorable or unfavorable, was often too much to bear. Mrs Kay, as Shlien (1961Shlien ( /2003 has pointed out, was potentially moving towards a process of "self-negation." Self-negation, according to Shlien (1961Shlien ( /2003, is a significant step towards developing psychosis. Self-negation follows low self-worth and whilst Mrs Kay reported a limited awareness of other peoples' feelings towards her, she also expressed feeling an unbearable anxiety at the idea of being viewed as an unacceptable person. She seemed to switch between closing off awareness of others' feelings to being extremely heightened and sensitive to others' feelings. This experience generally made life very stressful for Mrs Kay and she needed help.

Findings
(1) Developing mutual empathy Mutual empathy is proposed as a key issue in the development of mutuality in personcentered psychotherapy (Murphy, 2010). For mutual empathy to develop, first the client needs to be aware of the impact they have on the other person. Mrs Kay's sometimes limited reflexive awareness, fear of close intimate engagement within interpersonal relationships, affected the potential for psychological contact within the therapy relationship. Empathic reflections from the therapist were initially targeted on background aspects of experiences and mainly comprised information of the facts of her situation. The therapist sensed that this was the degree of being understood Mrs Kay could tolerate and that these background facts were what she wanted the therapist to know. However, as the therapist provided close empathic responses and tracked the client's process, the client's capacity for contact in the relationship increased. Over time, empathic reflections became targeted more on the meaning making process of Mrs Kay who subsequently responded by deepening reflection on her self-experience.
There are several features to empathic responding. Grant (2010) proposed the aim of the empathic response is to communicate to the client the therapist's understanding of the client's intended point of communication. This was a challenge for the therapist in this case. As the client moved in and out of contact the point of communication was not always apparent. In contrast, from a dialogical perspective empathy is "the attempt to understand" and that the aim is not "at immediately guessing and exactly naming the meaning of what the other person expresses." Instead, Schmid (2001, p. 55) describes empathy as "a common searching movement, a process, an ongoing joint checking." This description highlights the collaborative dialogic nature of empathy, both parties engaged in a mutual exploration of the client's self-experience and of the therapist's sensing and understanding of these.
To develop mutual empathy each person needs to recognize their impact on the other (Jordan, 2000). At times this seemed to challenge Mrs Kay's processing capacities. Moments where her reflexive awareness became heightened and incorporated the therapist's presence were too intense to hold in awareness. This was most evident when the therapist's empathic responses were met with dislocating utterances such as "err, I don't know" or "Err...no, no…" and a swift change of direction and content followed. In addition to this, Mrs Kay used expressions such as "oh, I don't know" or "I'm a bit all over the place" to metaphorically "move away" from self-experiences and hence turning attention away from the therapist's experience of her in the relationship. Mrs Kay could not hold in joint attention the therapist's experience of her.
These behaviors reflected Mrs Kay's need outside of the therapeutic relationship to maintain a distance between her and others. Such responses are proposed as intentional directional shifts by the client to maintain her self-concept. When working with the client in this anxious state, the therapist needed to maintain consistency in her acceptance for the client's experiencing, and eventually the client's sense of threat lessened. As the therapist's sustained attempt to communicate her experience of unconditional positive regard for all aspects of Mrs Kay's self-experience, this was gradually received by Mrs Kay. This process in therapy makes the "unfamiliar" "familiar" as more self-experiences previously inconsistent with the self-concept become integrated to the self-concept. For Mrs Kay, this came to include a capacity to recognize her impact on other people.
However, in empathic mutuality it is necessary that each person develops the capacity for experiencing and perceiving the other. In the extreme psychotic form of processing this capacity appears to be absent (Shlien, 1961(Shlien, /2003. However, Mrs Kay was acutely aware that other people had an awareness of her yet she was so fearful of their response it was too unbearable to "look." Mrs Kay had become highly sensitized to other people's views about her. Her self-worth was eroded so that she could not bear to see herself in another person's eyes. For a psychotic process to emerge a protective measure might be to negate the self, leaving experiences out of reflexive awareness. However, Mrs Kay maintained minimal levels of contact and instead made assumptions about how other people would respond to her. She was in contact but unable to accurately symbolize her impact on the other person. Jordan's (1997) proposed notion of relational efficacy meant that Mrs Kay could not assimilate a sense of herself as making an impact. She was at risk of moving further towards self-negation.
The therapist worked to maintain a close enough empathic responsiveness. Over several sessions the client began to respond and on occasions Mrs Kay would express her sadness or vulnerability and the therapist maintained an empathic stance: Mrs Kay: "I don't cry, I don't show vulnerability ever!" (tears falling down her face) Emma: "...but you have shown some vulnerability here…is that right?" Mrs Kay: "That is different, that is okay, as I know this is isolated and it will end and it's just here." Emma: "...it's important for you to know that it will stay where it is in this place." The following week Mrs Kay: "I am so miserable…no-one wants to be around this…I don't want to drag others down." Emma: "You can be miserable here...you think it maybe drags me down?" Mrs Kay: "You are here to listen. I never considered your feelings? This relationship only exists here and no other context, err..., so I don't think about that." In the example Mrs Kay expressed sadness, vulnerability as well as trust in the therapeutic relationship. Her expression partly indicated a concern about her impact on other people. The therapist's empathic reflection recognized this and included the possibility that she impacted the therapist. Mrs Kay's next response acknowledged this and that it had not been symbolized as a consideration in therapy. The therapist's reflection maintained enough empathic attunement to communicate unconditional acceptance of this expression. In response, Mrs Kay recognized this momentarily, and seemed to directly experience this in the moment, she accepted it in herself and acknowledged the therapist might be "dragged down." Mrs Kay's capacity for sustaining brief moments of shared awareness marked a shift towards mutual empathy. It is through a cyclical pattern of repeated moments of shared and joint attention, the shared awareness of impacting on another person that eventually gives rise to this as an acceptable self-experience. As reflexivity develop so it seems does the capacity for mutual empathy.
(2) Strategies for disconnection Mrs Kay had lived at the interface of a distressing relational system. As a consequence of this traumatic relational environment her self-concept was as a worthless and withdrawn person. She was unable to tolerate herself in relation to others and struggled to identify and express clearly her desires, needs or wants. In many ways she not only lacked a sense of self-worth but also lacked a purpose in life and as a result of her self-negation was not connected with her own agency. Person-centered theory suggests that an inherent aspect to the human organism is the tendency towards greater socialization, interpersonal relations and the pro-social nature of human beings. Aron (1996) states an inner drive for a meeting of minds and both Brazier (1993), and Benjamin (1988) proposed human infants have a developmental need not just to be known but to also to know others. The development of a capacity for interpersonal relating is sometimes thwarted when infants are raised in traumatic relational environments. A common result of traumatic environments is the development of heightened sensitivity to judgments.
As human infants develop they learn and acquire capacities for processing (Warner, 1998). Processing refers to the way we process information we encounter through our senses, within our environment, as well as internally generated self-experiences (memories, images, thoughts and emotions). We process information from the perceptual field and when this information supports and is consistent with existing judgments it is used to frame and direct subsequent judgments (Agrawal, Han, & Duhachek, 2013). Mrs Kay's processing style was characterized by a limited ability to "tolerate" herself reflexively. This was expressed, for example, either through doubting her newly found academic abilities, doubting the authenticity of her tutor's liking for her, and through self-criticism. Most strikingly of all, her struggle to tolerate being in a relation with the therapist. Warner's (1998) concept of fragile process highlights this difficulty. For many people they become emotionally overwhelmed in response to even the slightest hint of criticism. Mrs Kay's emerging tolerance to witness the impact she had was evidence of her increased processing capacity. However, the increased capacity for holding in awareness of her potential impact on others was a gradual one. The following excerpt from a midpoint session shows how the therapist and client discussed the potential for being judged. The therapist's close empathic tracking helped the client to feel heard and enabled her to stay with the feeling. Too much deviation from the precise intended communication and Mrs. Kay would have become distant and disconnected from the interaction: Mrs Kay: "..if I said, 'I'd like to do outreach work' I would be thinking you'd be thinking, 'Oh God, don't think you could do that.'" Emma: "…you'd be worried that I might be thinking that you are not good enough to do that..." Mrs Kay: "...oh I don't know! I'm all over the place, err...I don't know what I am saying." In the section above Mrs Kay disclosed her fear of people judging her. Although the therapist provided close empathic responses this soon became an intense exchange and Mrs Kay redirected her focus to being "all over the place." This example highlighted the tentative pacing that might be required when working with a client's fragile processing style. Also, how strategies for disconnection can be activated when psychological contact becomes intensified through close empathic tracking. The client's reflexive awareness of the therapist's experience of her seemed to almost overwhelm the capacity for processing and for staying in connection. The therapist respected the client's need and followed alongside. As the therapist did this the client went on to talk about her relationship with her parents and showed how outside of therapy her resourcefulness had developed alongside a greater capacity for witnessing her impact on another: Mrs Kay: "I don't like to upset mum and dad, it hurts me for days. Mum will go quiet for a few days and then contact me and ask 'I didn't upset you did I?' and I say, 'No you didn't' all bright and breezy." Emma: "All bright and breezy?" Mrs Kay: "yeah, it's enough to know that mother 'might have seen it,'...my pain or anger." Being seen by her mother was an important area of growth for Mrs Kay. To have her response of being angry or hurt registered by her mother had significant meaning for her. It showed to Mrs Kay that her capacity and awareness of impacting on her mother was developing. Mrs Kay reflected on her understanding of what the therapist might have thought about her and the conversation focused on her immediate feelings. The dialogue shows the tentativeness with which the mutual understanding unfolded and developed as the strategies for disconnection were gradually being replaced by increased capacity for contact: Emma: "...it's hard having someone not value what you love and err, you know?" Mrs Kay: "I don't know Emma: "You don't know?" Mrs Kay: "I don't know" Emma: "What don't you know?" Mrs Kay: "I don't know, ha ha ha (both laugh), I really don't know what I don't know, hum… (both laugh)." Emma: "I am just really noticing that you don't know (both laugh) and it is something that you step into ...like you change into I don't know and I am wondering about that?" Mrs Kay: "Don't ask me about that cause I really don't know (both laugh)… well it's these really deep and meaningful moments...and I think 'oh Mrs Kay you are talking rubbish', but I'm not, and something similar happened this week where the social worker rang me about the girl next door." Emma: "So this situation with the social worker was...that you somehow...you weren't making sense?" Mrs Kay: "I felt stupid." Emma: "And that stopped you in your tracks...where you weren't quite forthright... and got in to the, 'I don't know mode.'" Mrs Kay: "Yeah, I was like, 'I don't know, I don't know what you want from me' and then I get into stupid mode, not stupid, daft mode 'I don't know, I don't know what you want from me, I don't know what you want to hear, I don't know'... I am really sorry if this doesn't make sense. It is almost like everything is just jumbled up in my head and nothing I am saying makes sense." Emma: "So the...thing is kind of like 'oh before I really do look stupid' or before, is to kinda go, 'oh I don't know, I don't know, it's not me, I don't know!'?" Mrs Kay: "Yeah, that's spot on (laughing, then both laughing), that is absolutely spot on." (3) Client agency in mutuality The third key process identified in the development of mutuality was client agency. Bohart and Tallman (1996) active client perspective suggested that clients use the therapist's interventions and responses in ways they find most helpful for growth. All clients are basically engaged in a process of self-healing. Experiential therapies support and release the client's self-healing process. An example from the current case shows that through the process of therapy Mrs Kay became more self-accepting of "being-in-relation." She came to accept the unconditional positive regard in the therapeutic relationship and the reciprocal nature of unconditional positive regard meant she was then able to experience greater unconditional positive self-regard. Ultimately, Mrs Kay developed more accepting feelings towards others including regard for the therapist. As her relational efficacy increased and self-negation decreased, Mrs Kay became more aware of her agency in relationships. Some statements highlight this process of growth: Mrs Kay: "I find I can avoid conflict with my sons, I can wait and proceed, give them time to speak and see things from their side." Or in another statement the impact she had on her son was acceptable to her: Mrs Kay: "I have become an inspiration to my son! Who in response to being asked by his tutor why he wanted to be on the course said that he was inspired by his mum and all the hard work she had put in and the changes she had made in her life." Whilst reflecting on the separation from her partner: Mrs Kay: "People have been really kind to me since I split up with A, I seem to matter to them!" And later that session: Mrs Kay: "I cried all day on Monday, I was bereft, but happy to be free…it was an amicable break up…I never knew I could do that…we may even maintain a decent relationship…" Yet another way agency can be evidenced is from Mrs Kay's report on her ex-husband showing respect for her wish for him not to enter the house. Mrs Kay understood this to mean she could view herself as having an impact on others, that her growing self-belief enabled her to communicate her wishes, and that she felt more flexible in relationships. Finally, a feeling of being able to maintain her stance within interactions with other people also indicated growth in a sense of agency. The client's sense of agency and relational efficacy were apparent in the relationship with the therapist as it became more mutual and reflected developments in relationships outside of therapy.
The following brief examples show Mrs Kay's increased agency within the therapeutic relationship. In one exchange Mrs Kay came to an abrupt halt and said: This was later followed with: Mrs Kay: "I saw your eyes glaze over." These utterances stand in sharp contrast to the earlier disconnection typically experienced following a self-negating statement. Offering feedback to the therapist demonstrated curiosity about how the therapist experienced her; initiating an opportunity to increase mutuality and explore this together. On another occasion, when exploring whether the therapist had "got it right" Mrs Kay suggested she would "know more" than the therapist would about her own self-experiences. Mrs Kay's increased agency is evident in her sharing of experiences of being in relationship with the therapist.

Reflections on the relationship
Mutuality is shown here to be a process developed through a series of moments of connection and disconnection. The therapist used her knowledge of previous research, therapeutic supervision and the research interviews to create a conceptual framework from which to reflect on the therapy relationship. This enabled her to maintain her experiencing of unconditional positive regard and empathy for the client within the relationship. The therapist also reported that the process of "giving meaning" to events that happened within the therapeutic relationship helped the therapist to stay in connection when the intensity of psychological contact was fluctuating.
The impact of the client's involvement as a co-researcher cannot be isolated to methodological purposes as her reading of a draft case study had a further impact on her development. The client reported that being a part of the case study was empowering, particularly reading an earlier draft that contained significant overlapping biographical details of both the therapist and the client. Mrs Kay described feeling able to accept the therapist's "concern" and "interest" for her. The client's initial construct of the therapist as "expert" who would "do" the therapy to her, changed into the therapist as "real", "flawed" and "vulnerable." These shifts marked a contrast between being unable to tolerate knowing what others thought of her to the mutual exploration of the therapist's experience of her and her experience of the therapist. This was welcomed by the client and provided further opportunity to clarify misperceptions and misunderstandings. Mrs Kay offered these thoughts whilst experiencing joy, immediacy and transparency; communicating how much the therapeutic relationship had mattered to her and how her new found relational efficacy was now obvious to her in other significant relationships.
In this case study we have examined the process and development of mutuality. Table 1 provides an overview of the theory of mutuality known at the outset, what the case study has highlighted and areas for further study.
It has become clearer that mutuality develops through the client's experience of the therapist's consistent congruent, empathic understanding and unconditional positive regard; in the current case, the client's agency developed gradually, and a greater capacity for and intensifying of psychological connection enabled reflexive awareness to develop. As reflexive awareness developed mutual empathy emerged as the client and therapist considered the impact the client had on others.
Both clients and therapists have the potential to disconnect from each other within the therapeutic relationship. The therapist's strategies can be triggered through the client's narrative and supervision will typically provide the resource for the therapist struggling to stay in connection to the client. Therapists that maintain genuine unconditional positive regard and empathic understanding for the client through these difficult periods in the therapy will be able to support the client better and are more likely it seems to create therapeutic relationships that lead to the development of a mutual encounter.
An important issue to consider is the meaning of mutuality within the training and development of person-centered and experiential psychotherapists. In the case above it was clear that the therapist maintained her focus on the client's experience, even when the content of the client's experience triggered and touched upon personally meaningful events from her own life. Further research, using theory-building case studies, is recommended to extend and further permeate the theory of mutuality. Consider researching mutuality and client progress As mutuality developed the client experienced more agency in the relationship.
The role of selfdisclosure in developing mutuality The development of empathic mutuality emerged from the shared awareness of the client's insession experiencing