The therapeutic alliance remains the most robust predictor of psychotherapy outcomes across theoretical orientations and treatment modalities (Norcross & Lambert, 2018). However, building strong therapeutic relationships is inherently time-consuming, creating pressure for therapeutic adjuncts that can enhance engagement without compromising the collaborative, non-pathologizing principles central to effective therapy. This fundamental tension has created a significant gap in clinical practice: the need for structured therapeutic adjuncts that can accelerate rapport building and facilitate meaningful self-exploration without imposing diagnostic frameworks that shift the therapeutic focus from collaboration to categorization.

Traditional assessment approaches, while psychometrically sound, often create power imbalances between therapist and client, positioning the clinician as an expert interpreter of the client's experiences rather than a collaborative partner in exploration and discovery (Slade, 2009). These approaches typically prioritize diagnostic efficiency over therapeutic enhancement, potentially undermining the very alliance they should support.

The INSIGHT therapeutic adjunct (Identifying Needs, Strengths, and Inner Growth Harmony Tool) was developed to address this clinical gap by providing a structured yet non-diagnostic framework for client self- exploration. INSIGHT represents a methodical evolution from the validated SPOT tool (Screening Psychosocial Stressors Objectively Test), transforming it from a quantitative screening instrument into a qualitative therapeutic adjunct that maintains scientific rigor while enhancing therapeutic engagement and humanity.

Research Aim, Questions, and Objectives

Research Aim

The primary aim of this study was to develop and validate INSIGHT as a structured, non-diagnostic therapeutic adjunct for client self-exploration and therapeutic alliance enhancement. This research sought to address a critical gap in psychotherapy practice by creating a tool that could accelerate rapport building and facilitate meaningful self-exploration without imposing diagnostic frameworks that shift therapeutic focus from collaboration to categorization.

The study specifically aimed to bridge the persistent tension between the need for efficient therapeutic engagement and the imperative for client-centered, non-pathologizing care by establishing a new category of therapeutic adjuncts that merge empirical rigor with therapeutic humanity.

Research Questions

The study was systematically guided by three interconnected research questions that addressed theoretical, validation, and practical dimensions:

RQ1 (Theoretical Foundation): How can a structured qualitative model systematize projective techniques for reliable self-exploration within a non-diagnostic framework while maintaining therapeutic flexibility and client autonomy?

RQ2 (Validation Framework): What are INSIGHT's content validity, face validity, and clinical utility as assessed by expert panels and client feedback, and how do these measures demonstrate the tool's effectiveness as a therapeutic adjunct?

RQ3 (Clinical Application): How does INSIGHT generate therapeutic hypotheses and guide collaborative therapeutic dialogue in clinical practice while enhancing the therapeutic alliance without diagnostic labeling?

Research Objectives

Four specific, measurable objectives were established to systematically address each research question:

RO1 (Theoretical Integration Objective): Design a comprehensive 5-phase protocol that meaningfully integrates seven complementary therapeutic frameworks: contextual behavioral science, cognitive processing theory, psychoanalytic elements, cognitive-behavioral integration, client-centered approach, personality psychology, and grounded theory principles.

RO2 (Content Validation Objective): Establish robust content validity through systematic evaluation by a 9-expert panel representing diverse clinical backgrounds (psychiatrists, clinical psychologists, rehabilitation psychologists, and academicians), using Lawshe's Content Validity Ratio (CVR) methodology with a minimum threshold of 0.78 for validation.

RO3 (Face Validation Objective): Assess face validity and client acceptance through structured feedback surveys administered to all study participants, measuring relevance, clarity, comfort, helpfulness, collaboration, and actionability on validated 5-point Likert scales.

RO4 (Clinical Utility and Trustworthiness Objective): Demonstrate clinical utility and methodological trustworthiness through qualitative analysis of 30 clinical cases using Lincoln and Guba's comprehensive trustworthiness criteria: credibility (through triangulation, member checking, and peer debriefing), dependability (through audit trails), confirmability (through reflexive journaling and transparent documentation), and transferability (through thick description).

Methodological Framework Context

These research aims, questions, and objectives operated within a carefully constructed interpretivist paradigm, emphasizing that meaning is co-constructed through dynamic client-therapist interactions. This philosophical orientation aligned with contemporary collaborative therapy trends and recognized that therapeutic adjuncts must be validated for their capacity to enhance therapeutic processes rather than function as standalone measurement instruments.

The research structure deliberately moved away from traditional psychometric validation methods, instead employing qualitative trustworthiness criteria specifically appropriate for therapeutic enhancement tools. This approach represents a novel methodology for validating therapeutic adjuncts that prioritize clinical utility and therapeutic enhancement over conventional diagnostic capabilities while maintaining scientific rigor through established qualitative validation frameworks.

Theoretical Framework

INSIGHT synthesizes seven complementary theoretical frameworks to create a comprehensive yet flexible approach to client exploration:

1. Contextual Behavioral Science (Biglan & Hayes, 2016): Provides the foundation for Phase 1's contextual data collection, recognizing that behavior occurs within environmental and cultural contexts that must be understood for meaningful therapeutic work.
2. Cognitive Processing Theory (Rubenstein et al., 2001): Informs the analysis of response timing patterns, as emotional salience often manifests through processing delays or rapid defensive
3. Psychoanalytic Elements: Incorporates word association techniques for unconscious exploration, drawing on the rich tradition of projective methods while addressing their traditional limitations through structural frameworks.
4. Cognitive-Behavioral Integration (Beck, 1979): Utilizes connotation analysis to identify cognitive patterns and automatic thoughts that influence client experiences and responses.
5. Client-Centered Approach (Rogers, 1951): Maintains non-judgmental, collaborative therapeutic space throughout all phases, ensuring client autonomy and self-determination remain central.
6. Personality Psychology (Allport, 1937; Cattell, 1943): Connects individual responses to broader personality principles and individual difference patterns.
7. Grounded Theory (Glaser & Strauss, 1967): Guides thematic analysis approaches that emerge from client data rather than imposed theoretical categories.

This integration addresses contemporary calls for broader evidence bases in clinical practice (Levitt et al., 2024) while aligning with trends toward idiographic assessment that honors individual uniqueness (Sales et al., 2023).

This study employed a qualitative, exploratory design within an interpretivist paradigm, recognizing that meaning is co-constructed through dynamic client-therapist interactions. This philosophical orientation aligns with collaborative therapy trends and acknowledges that therapeutic adjuncts must be validated for their capacity to enhance therapeutic processes rather than as measurement instruments.

Validation Framework: Lincoln and Guba's (1985) trustworthiness criteria:

1. Credibility (The "Truth"): Is it truthful and accurate?
   • Triangulation: Data from 4 complementary phases (Context, Morals, Views, Aspirations) cross-verify each other.
   • Member Checking: Phase 5's report is verified and refined with the client – the ultimate check for accuracy.
   • Peer Debriefing: My research supervisor consistently reviewed the analysis process, challenging my assumptions and minimizing bias.
2. Dependability (The "Process"): Is the process consistent?
   • The Audit Trail: Our Excel system logs every step—raw data, clinician's categorizations, final interpretation. This makes the process perfectly transparent and replicable.
3. Confirmability (The "Objectivity"): Are the findings free from my bias?
   • The Audit Trail (Again): Proves conclusions are drawn from client data, not researcher
   • Reflexivity: I maintained a journal to bracket my own assumptions throughout the design
4. Transferability (The "So-What"): Can the insights apply elsewhere?
   • Thick Description: The framework generates incredibly rich, detailed case studies, allowing other practitioners to judge its applicability to their own clients and settings

Participants and Sampling

The study was conducted under the supervision of Dr. Somashekar Naraganti at BESTIU (Bharath Institute of Higher Education and Research). The research employed purposive sampling of 30 adults (≥18 years) receiving psychotherapy at the District Disability Rehabilitation Centre, Rajamahendravaram, India. This sample size follows Guest et al. (2006) recommendations for achieving thematic saturation in homogeneous populations.

Inclusion Criteria:

• Age ≥18 years
• Currently engaged in psychotherapy
• English proficiency sufficient for participation
• Ability to provide informed consent
• Willingness to engage in self-exploration and reflective dialogue

Exclusion Criteria:

• Acute psychiatric crisis requiring immediate intervention
• Active suicidality without adequate support systems
• Significant cognitive impairments affecting comprehension
• Communication barriers preventing meaningful participation

INSIGHT Protocol Structure

INSIGHT employs a five-phase protocol that operationalizes projective techniques within a structured framework:

Phase 1 – Client Present Condition: Collects baseline demographic and contextual information to establish the client's background and context.

Phase 2 – Exploring Client Morals:

A moral story: Missing Trophy is presented, and the client responds to five multiple-choice questions, selecting one word per question without time constraints. And the five chosen words are recorded as qualitative data, not linked to specific domains or mechanisms.

Phase 3 – Exploring Client Views:

Presents 20 predefined words: Family, Friends, Planning, Love, Hope, Strength, Faith, Job, Struggle, Fear, Relationships, Money, Happiness, Memories, Anger, Dreams, Weakness, Trust, Suspense, Violence, to the client, who responds with three unique associations within a 45-second timeframe. Responses are categorized into positive, negative, neutral, undisclosed and Timeout themes.

Phase 4 – Exploring Client Aspirations:

The client lists 10 favorite things and describes each using five unique words within 12 minutes. based on “what is the favorite thing” the favorite name is classified into any of these 20 Coping or Learning Mechanisms and the 5 favorite Responses are categorized into 16 thematic domains. 20 Coping or Learning Mechanisms: Watching, Listening, Playing, Reading, Socializing, Through Success Stories, Family Members, Petting, Praying, Visiting Native Place, Travelling, Singing, Eating, Writing, Drawing, Exercising, Drugs, Romancing, Sleeping, Love, after this is done the clinician categorizes the 5 unique words for each favorite thing into any of these 16 thematic domains: Family, Friends, Love, Patriotism, Personality Development, Horror, Suspense, Planning, Fiction, Fantasy, Nature, Memories, Hobbies, Philosophy, Spirituality, Romance.

Phase 5 – Structured qualitative thematic analysis Report based on client responses for structured questioning: Clinicians engage clients in reflective dialogue using the data gathered in the previous three phases. Structured qualitative thematic analysis Report based on client responses for structured questioning encourages deeper exploration of conscious and unconscious thoughts and feelings. Now, the clinician engages the client in structured questioning to delve deeper into their thoughts and feelings. Based on these 13 points

1. Clients Present Condition
2. Clients Preferred Areas of Development and Interest
3. Clients Learning and Coping Mechanisms
4. Clients Dominating Personality Traits
5. Clients Unpleasant Past Experiences
6. Clients Thinking Perspectives
7. Clients Outlook Towards Life
8. Clients Most Repressed Desires
9. Clients Distribution of Positive, Negative and Neutral Responses May Suggest
10. Client’s Time Taken for Responding May Suggest
11. Client’s Unique & Repeated Views Needs and Pressers About:
12. Clients Defense Mechanisms
13. Client’s Moral Reflection

Content and Face Validity Assessment

Content Validity: Nine experts (4 psychiatrists, 2 clinical psychologists, 2 rehabilitation psychologists, 1 academician) with 10+ years’ experience case evaluated INSIGHT using 5-point Likert scales across four dimensions: relevance, representativeness, comprehensiveness, and cultural neutrality.

Face Validity: All 30 participants completed post-session feedback via a 6-item, 5-point Likert scale survey assessing relevance, clarity, comfort, helpfulness, support for dialogue, and actionability.

Ethical Considerations

The study adhered to American Psychological Association (2017) and Rehabilitation Council of India ethical standards, with particular attention to:

• Non-pathologizing approach with no diagnostic labeling or scoring
• Comprehensive informed consent processes
• Immediate data anonymization with encrypted storage of identifying information
• Protection of vulnerable populations through careful screening procedures

Results

Content Validation Results

Expert panel evaluation yielded strong validation across all assessed dimensions. All Content Validity Ratios (CVR) exceeded Lawshe's threshold of 0.78 for nine experts, with individual phase CVRs ranging from 0.82 to 0.94. The Scale-Level Content Validity Index (S-CVI) reached 0.92, indicating excellent overall content validity.

Experts particularly endorsed INSIGHT's theoretical integration, cultural neutrality, and practical applicability. The tool's non-diagnostic approach received unanimous support, with experts noting its potential to enhance rather than replace traditional therapeutic processes.

Face Validity and Client Acceptance

Client feedback demonstrated strong acceptance and perceived utility, with a mean score of 4.6/5.0 (SD = 0.4) across all assessment dimensions. Ninety-two percent of participants rated the tool as "high" or "very high" across all items, indicating strong alignment with client-centered principles and practical utility.

Qualitative feedback highlighted several key themes:

• Collaborative Experience: Clients appreciated feeling like active participants rather than passive subjects
• Self-Discovery: Many reported gaining new insights into their values, motivations, and patterns
• Safety and Comfort: The non-diagnostic approach created a safe space for exploration
• Practical Relevance: Generated discussions felt directly applicable to their therapeutic goals

Clinical Utility Demonstration

Thematic analysis across all 30 cases revealed consistent patterns in INSIGHT's clinical utility:

Rapid Rapport Building: The structured yet collaborative nature of INSIGHT consistently accelerated therapeutic alliance formation, with most participants reporting increased comfort and trust within the first session.

Therapeutic Enhancement: The adjunct effectively identified patterns in clients' moral frameworks, cognitive styles, coping mechanisms, and aspirational themes, providing clinicians with rich material for therapeutic exploration without imposing diagnostic categories.

Client Agency Enhancement: The self-exploratory nature of INSIGHT consistently increased clients' sense of agency and ownership over their therapeutic process, countering the passive positioning often created by traditional approaches.

Methodological Rigor

While inter-rater reliability was deliberately not computed to avoid imposing quantitative rigidity on this qualitative tool, methodological rigor was ensured through:

• Comprehensive audit trails with timestamped Excel logs
• Member checking in Phase 5 where participants reviewed and refined interpretive themes
• Consistent peer debriefing and supervision throughout the analytical process
• Triangulation across multiple data sources and theoretical perspectives

Theoretical Contributions

INSIGHT makes several significant theoretical contributions to the therapeutic assessment literature:

Novel Integration: The synthesis of seven therapeutic frameworks into a single coherent protocol demonstrates how diverse theoretical orientations can be meaningfully integrated without compromising their essential principles.

Validation Innovation: The study establishes a validation framework specifically designed for therapeutic adjuncts that enhance psychotherapy, addressing a significant gap in therapeutic enhancement methodology literature.

Humanistic Empiricism: INSIGHT demonstrates that scientific rigor and humanistic principles are not mutually exclusive, creating a new category of evidence-based therapeutic adjuncts.

Clinical Practice Implications

The findings suggest several important implications for clinical practice:

Therapeutic Enhancement: INSIGHT provides a structured adjunct to psychotherapy that enhances alliance building while being both efficient and respectful of client autonomy, addressing a persistent challenge in contemporary therapy.

Process Enhancement: The adjunct generates therapeutically relevant insights quickly while maintaining depth and avoiding diagnostic labeling, supporting more collaborative therapeutic processes.

Training Applications: The structured yet flexible nature of INSIGHT makes it suitable for training purposes, helping developing clinicians learn to integrate multiple theoretical perspectives while maintaining focus on therapeutic enhancement and client experience.

Limitations and Considerations

Several limitations must be acknowledged:

Methodological Limitations: The sample size (n=30), while appropriate for qualitative validation, limits generalizability. The study's cultural specificity (Indian context) may require adaptation for other cultural contexts. The tool's dependence on clinician interpretation introduces variability that may affect consistency across practitioners.

Theoretical Limitations: INSIGHT enhances therapeutic exploration rather than providing diagnostic certainty, requiring integration within broader therapeutic processes. The structured protocol may occasionally constrain exploration of emergent themes that fall outside the framework.

Practical Limitations: The tool is time-intensive (60-90 minutes), potentially challenging for brief therapy contexts. It requires English proficiency and clinician training in thematic analysis, which may limit accessibility in some settings.

Cultural Considerations

While the expert panel confirmed strong cultural neutrality, the tool's development and initial validation in an Indian context suggests the need for careful cultural adaptation in other settings. The use of universal themes (family, trust, hope) and culturally neutral stimuli supports broader applicability, but empirical validation across diverse cultural contexts remains necessary.

Implications for Future Research

This study opens several important avenues for future investigation:

Immediate Priorities:

1. Multilingual Adaptation: Development and validation of INSIGHT in multiple languages to increase accessibility and cultural appropriateness.
2. Digital Platform Development: Creation of user-friendly digital interfaces to improve accessibility and data management while maintaining the tool's collaborative nature.
3. Training Protocol Standardization: Development of standardized training curricula for practitioners to ensure consistent implementation.

Long-term Research Agenda:

1. Longitudinal Outcome Studies: Investigation of INSIGHT's impact on therapeutic alliance, client engagement, and clinical outcomes over extended periods.
2. Comparative Effectiveness Research: Systematic comparison with other assessment approaches to establish relative efficiency and therapeutic benefit.
3. Cross-cultural Validation: Adaptation and validation across diverse cultural contexts to establish broader applicability and identify necessary modifications.

The development and validation of INSIGHT represents a significant step toward bridging the persistent gap between empirical rigor and therapeutic humanity in clinical practice. By creating a structured yet non- diagnostic therapeutic adjunct for client self-exploration and psychotherapy enhancement, INSIGHT demonstrates that scientific validation and humanistic principles can be meaningfully integrated.

The adjunct's strong content validity (S-CVI = 0.92) and high client acceptance (4.6/5.0) provide empirical support for its theoretical foundation and practical utility in enhancing psychotherapy. More importantly, the consistent demonstration of enhanced therapeutic alliance, meaningful therapeutic exploration, and increased client agency suggests that INSIGHT addresses real clinical needs in contemporary psychotherapy practice.

INSIGHT establishes a new category of therapeutic adjuncts that prioritize collaboration over categorization, exploration over diagnosis, and client agency over clinical authority. This approach aligns with contemporary trends toward personalized, client-centered care while maintaining the structured approach necessary for efficient therapeutic enhancement.

The implications extend beyond the adjunct itself to the broader question of how therapeutic enhancement tools can support rather than supplant the collaborative relationships that drive therapeutic change. By demonstrating that structured exploration can enhance rather than constrain therapeutic dialogue, INSIGHT provides a model for future developments in psychotherapy adjuncts that honor both scientific rigor and human dignity.

As psychotherapy continues to evolve toward more personalized, culturally responsive, and collaborative approaches, therapeutic adjuncts like INSIGHT that bridge empirical validation with humanistic principles become increasingly essential. The successful integration of multiple theoretical frameworks within a single coherent protocol suggests promising directions for future therapeutic innovation that respects both the complexity of human experience and the necessity of evidence-based practice enhancement.

Acknowledgments

The authors extend sincere gratitude to Dr. Somashekar Naraganti for his invaluable guidance and supervision throughout this research. Special thanks are also due to the District Disability Rehabilitation Centre, Rajamahendravaram, and all participants who contributed their time and insights to this study. We acknowledge the institutional support from BESTIU that made this research possible.

Author Information

Satish Narni - Doctoral candidate, Department of Psychology, BESTIU. Reg. No. 2023WPPSY009.

Dr. Somashekar Naraganti - Research Supervisor and Guide, Department of Psychology, BESTIU

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