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Therapist Variables in Psychotherapy

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 Journal of Integrative Research, Counselling and Psychotherapy, vol.1, no.2,
November 2012

Therapist Variables in Psychotherapy

Oana-Maria Popescu

Abstract
Therapist variables significantly contribute to the therapeutic outcome. Therefore, a
classification of these variables proves useful for a better understading of the potential
therapeutic outcome. Therapist variables are classified in relational, professional,
demographic and diversity, personality, developmental and personal.
Key words: therapist variables, common factors, integrative psychotherapy

Many authors suggest that therapist variables significantly contribute to

therapeutic outcome (Guthrie, 2000). Specific variables (like therapeutic techniques),
and nonspecific variables (aspects of client-therapist relationship) influence
therapeutic outcome more than situational variables (demographic characteristics, the
therapist’s theoretical orientation and experience) (Beutler, Machado & Nenfelt,
1994).
Specific variables are therapeutic interventions and techniques identified by
psychotherapists as being important components of an efficient therapeutic process.
Non-specific variables are factors supporting the therapeutic relationship, typically
attributed to Carl Rogers’ model of facilitating conditions for a therapeutic alliance. In
any case, psychotherapists are not equal regarding their therapeutic abilities: by
contrary, there are significant differences in therapeutic efficiency (Blatt et. al., 1996).
Sandell et. al. (2007) estimate that therapeutic variables account for 9% of the
variance in treatment outcome.
In the classic training film “Gloria” (Shatrom, 1965) trainees watch a young
woman called Gloria being interviewed in the same day by Albert Ellis, Fritz Perls
and Carl Rogers. The purpose of this exercise is to demonstrate the differences in the
three therapists’ theoretical orientation, about whom Gloria said were equally
efficient, though each of them in his unique way.
In classifying therapist variables I took into account the work of Truax &
Carkhuff (1967), Strupp (1973), Ricks (1974), Holloway & Wampold (1986),
Lambert (1986), Greencavage & Norcross (1990), Horwath & Symonds (1991),

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 Journal of Integrative Research, Counselling and Psychotherapy, vol.1, no.2,
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Svartberg & Stiles (1991), Weiberger (1993), Blatt et. al. (1996), Dunkle &
Friedlander (1996), Guthrie (2000), Hersong et. al. (2001), Beutler et. al. (2003),
Vocisano et. al. (2004), Tatman (2005), Sandell et. al. (2007), Nelson-Jones (2009),
Robinson (2009), Tolan (2011), and Zimmerman & Bambling (2012). I propose the
following classification of therapist variables (table 1):

Relational variables: empathy, attachment style, unconditional positive regard,

respect, warmth, genuineness.
Professional variables: theoretical orientation, training level, experience, the
therapist’s view on psychotherapy, activity/neutrality, overall caseload, supervisory
status.
Demographic and diversity variables: age, gender, race, ethnicity, values, client-
therapist similarities.
Personality variables: personality traits, attitudes, flexibility, kindness,
trustworthiness, adjustment capacity.
Developmental and personal variables: the therapist’s level of personal
development, the therapist’s functioning level, self-efficacy, degree of self-directed
hostiliy, interpersonal problems, introjects.
Table 1. Therapist variables

Therapist relational variables

Empathy
Empathy is an affective response more appropriate to someone else’s situation
than to one’s own; it is an emotional reaction in an observer to the affective state of
another individual (Blair, 2007).
Empathy literally means the power of understanding things outside ourselves
(from the Greek empatheia). The ability to relate to those feelings an individual sees
expressed by others depends on an ability to compare them with those the individual
may have experienced himself/herself, which allows inference of what the other
person must be going through (Farrow & Woodruf, 2007). Empathic intuitiveness and
perception are the result of the individual’s cumulative psychosocial development and
subjective experience of life. Most empathic responses occur automatically, but
humans are also capable of voluntarily focus their empathy on others (de Greck et. al.,

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 Journal of Integrative Research, Counselling and Psychotherapy, vol.1, no.2,
November 2012
2012). Empathy involves both a perception of the other and an understanding of that
perception.
If the therapist recognizes but remains outside the experience of the client, this
is external empathy (Hart, 1999). Deeper empathy occurs when the therapist can think
and feel into the inner life of the client. But in the same time, the clinician needs a
clear separate sense of self, attempting to be an observer who compares what he/she
imagines the client experiences to his/her own repository of similar experiences.
Emptahic closeness is, paradoxically, dependent on an ability to distance oneself from
another, in order to be able to observe the other without distorsion. Although the
therapist senses what is like to be where the client is, he/she retains an own identity.
This is accomplished by imagining and modelling, or mirroring the client to better
experience what the world is like through the client’s eyes (Hart, 1999). Occasionally,
the therapist may experience particular emotions, thoughts and body sensations that
seem to come from the client, and needs to make the difference between own
emotions, thoughts and sensations and those of the client. In such instances it is useful
to tell the client what happens, especially if the therapist feels certain emotions that
the client doesn’t seem to display.
According to Miller (2010) empathic responses are of two types: validating
and limit-setting. Validating responses mirror the client’s feelings, experiences and
behaviours, allowing the client to feel heard. Limit-setting responses allow the
clinician to create an environment of protective containment and an atmosphere of
safety in the session, which functions to encourage the client’s growth (e.g. if the
client constantly interrupts the therapist, the latter can note the behaviour and interpret
it as a way of expressing what the client feels, at the same time encouraging the client
to express feelings in another way).
Empathy is a multiphased process, involving a series of experiences, including
the therapist attunement with the client’s experience, the therapist’s expression of
empathy and the client’s reception of it (Wynn & Wynn, 2006). Empathy is often
described as either an affective phenomenon (affective empathy), relating to the
emotions of the client, or as a cognitive construct (cognitive empathy), refering to the
intellectual understanding of the client’s experiences.
According to Elliott et. al. (2011) therapeutic empathy is expressed in three
main modes:

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November 2012
- empathic rapport: the therapist exhibits a compassionate attitude toward the client
and tries to demonstrate an understading of the client’s experience;
- communicative attunement: an active, ongoing effort to stay attuned on a moment-
to-moment basis with the client’s communication and unfolding experience;
- person empathy: a sustained effort to understand the kinds of experiences the client
had, both historically and presently, that form the background of the client’s current
experiencing.
Empathy can be classified as subjective, interpersonal and objective (Clark,
2010):
1. Subjective empathy relates to the therapist’s awareness of his/her sensibilities and
internal reactions in response to the experiencing of a client. When attempting to
empathically understand a client, the therapist engages in a process involving
identification, imagination, intuition and felt-level experiencing. When a therapist
empathizes with a client, there is often a perceived similarity of experiences which
evokes a level of identification, even if it lasts for only a moment. Through the
process of identification with the client, the therapist may engage in imagination in a
quest to infer what it is like to be the client. Intuition relates to the therapist’s
sensitivity to immediate responses and hunches that come to mind in interactions with
a client. Felt-level experiencing refers to resonating with a visceral sensation with the
client, the therapist reacting in a bodily felt way to evocative expressions of a client.
2. Interpersonal empathy involves perceiving a client’s internal frame of reference and
conveying a sense of the private meanings to the person. The therapist can
empathically understand the client on an immediate here-and-now basis and also
develop a general sense of how the client experiences life from an extended empathic
perspective.
3. Objective empathy relies on a consensus of judgements from reputable refrence
groups composed of individuals external to a client’s frame of reference.
Responding empathically can assist the therapeutic process in five ways
(Miller, 2010): by building rapport and the working alliance with clients; by
encouraging client exploration of feelings, thoughts and behaviours; by allowing the
client to explore ambivalence toward change; by providing methods to clarify client
responses in sessions; and by providing the foundationfor later interventions.
Empathy is the first ‘intervention’ in the therapeutic arsenal, since it reflects the

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November 2012
understanding of the client at an emotional level, therefore employing the right
hemisphere, which ‘feels felt’.
Shared emotions and physiological arousal experienced between client and
therapist contribute to the empathic connections developed during psychotherapy. A
much stronger working alliance is formed in therapy when clients perceive their
therapists as communicating higher levels of empathy (Stebincki, 2008).
Based on meta-analyses, Elliott et. al. (2011) make the following clinical
recommendations:
- an empathic stance on the part of the therapist is an essential goal, regardless of
theoretical orientation;
- therapists must make efforts to understand their clients and demonstrate this
understanding through responses that address the perceived needs of the client;
- therapist responses that accurately answer to and carry forward the meaning in the
client’s communication are highly useful: empathetic understanding responses convey
the understading of client experience, empathic affirmations are attempts by the
therapist to validate the client’s perspective, empathic evocations try to bring the
client’s experience alive, and empathic conjectures attempt to get at what is implicit in
the client’s narratives but not yet articulated;
- by expressing empathy therapists assist clients in symbolizing their experience in
words, and track their emotional responses, so that clients can deepen their experience
and reflexively examine their feelings, values and goals;
- empathy entails individualizing responses to certain clients: fragile clients may find
the usual expression of empathy too intrusive, while hostile clients may find empathy
too directive;
- empathy has to be offered with humility and ready to be corrected: therapists must
remember that they are not mind readers and that clients may not feel understood even
if the therapist makes every effort in understading them;
- therapists should seek to offer empathy in the context of positive regard and
genuineness.
An interesting observation is that humanistic/experiential and psychodynamic-
oriented therapists have the tendency to view empathy as an innate ability, while
behaviourists are more likely to view empathy as a skill (Carlozzi et. al., 2002). These
findings suggest that there is some consistency between theoretical identification and
the use of and views of empathy.

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November 2012
Unconditional positive regard
In 1957 Carl Rogers published an article with the title „The necessary and
sufficient conditions of therapeutic personality change”, which emphasized three
basic conditions for therapeutic change: empathy, unconditional positive regard and
genuineness.
Tolan (2011, p. 18) presents the following pre-conditions for therapeutic
change:
1. two individuals are in contact;
2. the first individual, called client, is in a state of incongruency, being
vulnerable and anxious;
3. the second individual, called therapist, is congruent in the relationship;
4. the therapist manifests unconditional positive regard for the client;
5. the therapist manifests an empathic understanding for the client’s internal
frame of reference;
6. the client more or less perceives the unconditional positive regard and
empathy demonstrated by the therapist.
The first precondition in the therapist-client interaction is psychological
contact. The level of psychological contact determines differences in therapeutic
relationships: when individuals feel uncomfortable, theratened or angry the
psychological contact can be blocked. Both therapist and client have a certain
availability for psychological contact, depending on personality and cultural variables.
Each individual has a certain „tolerance window” (Tolan, 2011): some things to
which he/she adapts more easily, and certain behaviours which trigger whitdrawal.
For therapists, certain clients can be more difficult to work with than others, and it is
sometimes hard to be supportive within the limits of own tolerance window.
Unconditional positive regard is acceptance of the client’s expression of
negative and positive feelings, and of the client consistencies and inconsistencies. It
means a caring for the client as a separate person, with permission to have his/her own
feelings and experiences (Wilkins, 2000, p. 24)
In contrast to unconditional positive regard, conditional positive regard is the
offering of warmth, respect, acceptance, etc, only when the other fulfils some
particular expectation, desire and requirement. In terms of client-centred therapy,
when a child receives conditional positive regard from parents/caregivers, there may
be a resulting distorsion in the development of conditions of worth. Conditional

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November 2012
positive regard can occur in therapy when the therapist has an agenda different from
that of the client and acts to reward appropriate behaviour (Wilkins, 2000).
Unconditional positive regard promotes the self-acceptance of the client and
this allows change. For therapists the challenge sometimes comes from wanting their
clients to change and perhaps even from a vision of what change might lead to, but for
some clients only when this desire is let go does change become possible. The
psychotherapist’s ability to provide positive regard is significantly associated with the
therapeutic outcome. Unconditional positive regard directly addresses the client’s core
sets and the impaired right hemispheric functions.
Farber & Doolin (2011, pp. 62-63) offer the following recommendations for
clinical practice:
- positive regard may, in some cases, be sufficient by itself to effect positive change,
and, at a minimum, sets the stage for other interventions;
- there is no research-driven reson to withhold positive regard;
- positive regard serves various functions: streghten the client’s ego and belief in
his/her capacity to be engaged in an effective relationship; positive reinforcer for the
client’s engagement in the therapeutic process, including difficult self-disclosures;
facilitate the client’s natural tendency to grow and fulfill own capacity as a human
being;
- positive regard may be particularly important in situations wherein a nonminority
therapist is working with a minority client;
- therapists should ensure that their positive feelings towards the clients are
communicated to them: the therapist communicates a caring, respectful, positive
attitude that serves to affirm a client’s basic sense of worth;
- therapists need to monitor their positive regard and adjust it as a function of the
needs of particular clients and specific clinical situations.

Genuineness
Congruence/genuineness means that the therapist is openly being the feelings
and attitudes which at the moment are flowing within him/her, and not hiding behind
a professional role or holding back feelings that are obvious in the encounter (Kolden
et. al., 2011).

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November 2012
Genuineness is related to terms like congruence, autehnticity, openness,
honesty and nonphoniness. Genuineness has two facets: the therapist is able to be in
touch with his/her own experience (internal congruence) and has the ability to reveal
his/her experience to the client (transparency or external congruence). In other words,
the therapist is able to use both the right and left hemipshere in order to communicate
with the client, addressing the client at the level of plastic self and core self.
Kolden et.al. (2011, p.70) make the following recommendations regarding
clinical practice:
- therapists must embrace the idea of striving for genuineness with their clients;
- therapists can mindfully develop the intrapersonal quality of congruence;
- therapists can model congruence;
- the maintenance of congruence requires that therapists be aware of instances when
congruence falters;
- it is important for therapists to identify and become aware of their congruence style
and to discern the differing needs, preferences, and expectations that clients have for
congruence;
- congruence may be especially important in younger, less educated, and perhaps less
sophisticated clients;
- congruence appears to be especially apparent in psychotherapy with more
experienced practitioners.

The therapist’s attachment style

Research on the relationship between attachment styles and psychotherapy
outcomes focused on three main aspects (Meyer & Pilkonis, 2001):
1. The relationship between the client’s attachment style and the therapeutic outcome
(see the sub-chapter on client variables);
2. The relationship between the client’s attachment style and the therapeutic alliance;
3. The relationship between the therapist’s attachment style and the therapeutic
outcome.
The therapist’s attachment style influences both the therapeutic process and the
therapeutic outcome in various ways (Brisch, 1999, Daniel, 2006, Meyer & Pilkonis,
2001, Slade, 1999):
- Therapists with a preoccupied attachment tend to have less empathic responses,
probably due to their fear of rejection;

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November 2012
- Complementary attachment styles are advantageous in psychotherapy: clients with a
preoccupied attachment style benefit more from a relationship with an avoidant
therapist and vice-versa;
- Avoidant therapists may be less responsive to clients in comparison to securely
attached therapists, while preoccupied therapists may become compulsive carers;
- An insecure attachment in the therapist may influence his/her capacity to promote a
secure attachment in clients;
- Working with the client’s conflicts can induce considerable anxiety in the therapist
and if the clinician does not have a secure base the client may not be capable to
tolerate the therapist’s anxiety and may engage in defensive processes and resistance;
- A therapist who is sensistive to rejection indicators may have to fight his/her own
emotional processes when working with a rejecting client;
- In order to understand the client’s experience, the therapist must first understand
own attachment style;
- While the client’s past experiences determine him/her to seek therapy, the therapist’s
past experiences seem to be at least partly responsible for choosing the profession of
psychotherapy. According to Fussel & Bonney (1990), there is a higher incidence of
childhood trauma, emotional deprivation and parent-child role inversions in therapists
in comparison to the general population. These factors may negatively influence the
therapeutic relationship if the therapist avoids the client’s pain of identifies
himself/herslef with the client’s pain.
Studies regarding therapist attachment styles vary greatly: while some studies
show that 70 to 90% of psychotherapists have a secure attachment style (Leiger &
Casares, 2000, Ligiera & Gelsa, 2002), other studies suggest that only 20% of
therapists have a secure attachment (Nord, Hoger & Eckert, 2000). In any case, adult
attachment styles can be changed in therapy or in a secondary attachment relationship,
which allows the individual change internal working models (Hopkins, 2006, Stekley,
2006).

Therapist professional variables

The main professional variables with an impact on therapeutic outcome are:

theoretical orientation, training level, experience, the therapist’s view on
psychotherapy, activity/neutrality, overall caseload and supervisory status.

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November 2012
Theoretical orientation
The specific therapeutic interventions or techniques used by psychotherapists
belonging to various theoretical orientations are specific variables. Each
psychotherapy orientation adheres to a specific theory conceptualizing therapeutic
change, and each psychotherapy school promotes own techniques that are thought to
be very important in influencing human change. But research shows that specific
variables are responsible for only 15% of the therapeutic outcome, while nonspecific
variables contribute to the therapeutic outcome to a much larger extent (Guthrie,
2000).
Training level
The degree to which a therapist adheres “therapy manuals” influences
therapeutic outcome, in the sense that less flexibility the therapist shows, less the
chances of client improvement (Blatt et. al., 1996). Global professional training also
seems to have an impact on therapeutic outcome (Lyons & Woals, 1991), with a slight
outcome advantage when therapy is conducted by a psychologist rather than a
psychiatrist (Vocisano et. al., 2004).
Experience
The number of years a clinician practiced individual psychotherapy is not
related to client outcome. Still, clinical supervisors have superior performance
(Vocisano et. al., 2004). Generally, the therapist’s level of experience is not found to
be predictive of client alliance ratings, but premature dropout of clients from therapy
has been found more frequently with inexperienced than experienced therapists,
which means that experience makes a difference for the therapeutic relationship.
Therapists with more than 6 years of experience have a high percentage of clients who
improve and a very low percentage of clients who deteriorate during the course of
therapy (Sandell et. al., 2006). Certain studies (Svartberg & Stiles, 1991) show that
psychodynamically-oriented therapists are less effective the more experienced they
are, in contrast to cognitive-behavioural therapists. In psychodynamic therapy a
neutral stance is emphasized and encouraged in training programmes. Experienced
dynamic therapists, in order not to compromise the neutral stance, tend to refrain from
support, reassurance, education and role preparation for clients in the beginning of
therapy. On the other hand, experienced therapists might start challenging resistance
and defenses too early, while those less experienced may be eager to avoid frustrating

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November 2012
clients or hurting their feelings. Last but not least, some very experienced therapists
may feel less enthusiastic about their clients.
The therapist’s view on psychotherapy
If the therapist views psychotherapy as a form of artistry, therapeutic
outcomes are significantly improved (Sandell et. al., 2006).
Activity/neutrality
Many clients prefer active therapists, and neutral therapists can be perceived
as too little involved (Hersong, 2006, Svartberg & Stiles, 1991).
Overall caseload
The overall caseload of the clinician may have an influence on client care in
the situation of burnout. Burnout is a syndrome of emotional ehaustion and cynicism
that frequently occurs as a result of constant or repeated emotional pressure associated
with an intense involvement with people over long periods of time (Vocisano et. al.,
2004). Burnout involves loss of concern and positive feelings for clients and a decline
in the quality of service.
Supervisory status
Supervisory status and self-identified primary orientation are related to
symptom change. The best therapeutic outcome is facilitated by therapists who use a
sophisticated blend of cognitive-behvaioural and interpersonal/psychodynamic
approaches (Vocisano et. al., 2004).

Demographic and diversity variables

The main demographic and diversity therapist variables influencing
therapeutic outcome and working alliance are: age, gender, race, ethnicity, values and
client-therapist similarities.
Therapists who are more tha 10 years younger than their clients obtain poorer
outcomes then older therapists or those of similar age to their clients (Vocisano et. al.,
2004).
Gender and race do not seem to have a significant impact on the therapeutic
outcome (Guthrie, 2000).
Ethnic similarity between therapists and clients predict therapy outcomes
(Vocisano et. al., 2004).
Therapists communicate their values to clients, and therapists’ judgements of
clients’ improvement in psychotherapy have been found to correlate with the extent to

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November 2012
which clients appear to adopt the values of their therapists. In other words, treatment
is experienced as effective when the therapy participants begin with differing value
perspectives, but close the gap as therapy progresses. Generally, clients rate sessions
as more negative and less engaging if their therapists hold dissimilar values (Sandell
et. al., 2006).
Client- therapist similarities seem to promote a better therapeutic alliance
(Sandell et. al., 2007).

Personality variables
The main therapist personality variables are: personality traits, attitudes,
flexibility, kindness, trustworthiness and adjustment capacity.
Personality traits
Higher neuroticism scores on the NEO-FFI are related with higher client-rated
working alliance scores (NEO-FFI consists of five domains of personality:
neuroticism, extraversion, openness, agreeableness and conscientiousness) (Tatman,
2005).
Flexibility, kindness and trustworthiness are important factors in determining the
therapeutic outcome and the evolution of the therapeutic alliance (Beutler et. al.,
2003).
Adjustment capacity
The higher a therapist’s adjustment capacity, the better the therapeutic
outcome. Therapists should view their roles in the following ways: help the client
avoid, adapt to, and control elements of their problems; provide concrete advice, goals
and education; and initiate or take some lead in sessions (Zimmerman & Bambling,
2012).

Developmental and personal variables

The developmental and personal therapist variables are: the therapist’s level of
personal development, the therapist’s functioning level, self-efficacy, degree of self-
directed hostiliy, interpersonal problems and introjects.
The therapist’s level of self-development. Therapists with low levels of
emotional disorders have the best therapeutic results (Rogers, 1989).
The therapist’s functioning level is positively correlated with therapeutic
outcome (Tatman, 2005).

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November 2012
Self-efficacy is a stronger predictor of performance than training and
experience, and is related to therapist well-being and cultural attitudes (Beutler et. al.,
2003).
Degree of self-directed hostility. The therapist characteristics associated with a
better working alliance are less self-directed hostility, more perceived social support,
higher degree of comfort with closeness in interpersonal relationships, empathy, non-
possessive warmth and genuineness (Vocisano et. al., 2004).
Interpersonal problems. The therapist’s interpersonal problems are predictive
of less favourable working alliance. A dominant style in the therapist is positively
related to the quality of alliance, which may reflect the clients’ preference for
therapists with a structured and active involvement in theraoy, as opposed to a neutral
attitude (Hersong et. al., 2006). Therapeutic outcome is positively correlated with the
psychotherapist’s psychological health (Lumborsky et. al., 1985).
In sum, the better the psychotherapist’s regulatory capacity at all levels of the
self, the better the therapeutic outcome.

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