Psychotherapy
Volume 24/Fall 1987/Number 3
THE PERSON OF THE THERAPIST
IN PSYCHOTHERAPEUTIC PRACTICE
E. A. McCONNAUGHY
Vanderbilt University
The nature of the therapist's approach
to clients is determined by who the
therapist is as a person. The personal
development, interpersonal style, and
life experiences of the therapist shape
the emotional climate, theoretical
perspective, and techniques that the
therapist offers to clients when they
present for treatment. A wealth of
clinical and theoretical writings
underscore the relevance of the
therapist's personal contribution to
the quality of the therapy, and the
psychotherapy research literature
supports and strengthens this position.
Use what language you will,
you can never say anything
but what you are.
—Ralph Waldo Emerson, 1860
The role of the therapist as a person within the
therapy relationship is an intriguing area of inquiry
for the field. It is natural that therapists, who
devote their emotional and intellectual energies
to understanding human nature and interpersonal
relationships and using this knowledge to facilitate
beneficial change in these domains, are interested
in the imprint they make on the process. There
are narcissistic rewards for us as psychotherapists
(cf. Finell, 1985), for to understand our contribution
is to understand ourselves (Reik, 1948). A therapist's contribution is affected by such important
factors as the individual characteristics of clients
The author wishes to express special thanks to Marianne
Johnson, Hans Strupp, and Forrest Talley.
Reprints may be ordered from E. A. McConnaughy, The
Bayview Center, 6 Fort Street, Quincy, MA 02169.
and qualities of the setting; however, there are
overarching personality characteristics of the
therapist that transcend particular therapeutic relationships, clients, and techniques and that exert
an influence on the therapist's practice of psychotherapy.
It is my main thesis that it is the character and
interpersonal style of the therapist that determine
the nature of the therapy that is offered to clients.
The actual techniques employed by therapists are
of lesser importance than the unique character or
personality of the therapists themselves. Therapists
select techniques and theories because of who
they are as persons: the therapy strategies are
manifestations of the therapist's personality. The
therapist as a person is the instrument of primary
influence in the therapy enterprise. A corollary
of this principle is that the more a therapist accepts
and values himself or herself, the more effective
he or she will be in helping clients come to know
and appreciate themselves.
This conclusion emerged as a result of my own
experience. For me, it was important to acknowledge that I could not be my supervisors, I could
not be the authors whose techniques I read about,
I could not be the master clinicians I observed on
videotape or on stage. I could only be myself; I
could only do what felt comfortable and solidly
connected to who I am. Theodor Reik (1948)
describes the sentiment: "And this is the blessing
of such loneliness: he who is always listening to
the voices of others remains ignorant of his own.
He who is always going to others will never come
to himself" (p. 507). While we can learn the
techniques of others, and these techniques can
enhance our work, we cannot precisely duplicate
our teachers. Any techniques we select will become
distilled into our own special style of interacting
with clients.
In the same way that techniques are expressions
of the therapist, theories also reflect the personality
characteristics and life experiences of their orig-
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E. A. McConnaughy
inators. Stolorow & Atwood (1979) wrote: "Every
theory of personality . . . [is] bound up with the
theorist's personal reality and precedes his intellectual engagement with the problem of human
nature" (p. 17). Using a psychobiographical model,
Stolorow & Atwood describe the influence of personal experiences on the theories of Freud, Jung,
Reich, and Rank. For example, Freud's need to
maintain an idealized image of his mother forced
him to deny his ambivalence toward her; the splitoff negative feelings were internalized, displaced
onto the father, and attributed to the psychology
of girls, and these reactions made their mark on
Freud's theory of psychosexual development
(Stolorow & Atwood, 1979). Jung's personal
concerns about self-dissolution and isolation led
to his proposed solution of the collective unconscious (Stolorow & Atwood, 1979).
Theories of personality emanate from life experience; theories of therapy arise from clinical
experience. Gifted clinicians attempt to spell out
what they do based on their experience, and from
these specifications spring theoretical models. A
typical pattern is that over time the theory becomes
the guideline for future clinical endeavor. This
can be problematic if the theory is transformed
into a rigid structure and clinicians spend their
energy and attention arguing over fine points of
someone else's theory, rather than listening to
their own clinical experience.
This is not to suggest that theories and techniques
can be dismissed as unimportant. Indeed, Prochaska
& DiClemente (1983; DiClemente & Prochaska,
1982, 1985) have shown that people changing on
their own implement the same techniques used
by therapists and that these self-changers are successful without the help of a therapist. Stiles et
al. (1986) also point out that positive change does
not necessarily and in all cases require the presence
of a therapist (e.g., Emrick et al., 1977; Hurvitz,
1974). The person of the therapist does not provide
the sole reason for the success or failure of a
treatment. Such factors as who the client is, the
setting, and the techniques used exert important
influences. As stated previously, techniques can
be learned and this learning can enhance practice.
Individual clients and particular relationships and
settings influence a therapist's manner. However,
the person of the therapist is the primary determinant of the type and quality of the psychotherapy
offered to a client.
Clinical and Theoretical Literature
Much of the theoretical literature emphasizes
304
the need for the therapist to be a personally welldeveloped individual who is relatively comfortable
with the vicissitudes of his or her character structure, and who functions effectively in interpersonal
relationships.
Freud (1905/1953) believed that the therapist's
personality was of critical importance in the therapy
endeavor. He wrote: "It is not a modern dictum
but an old saying of physicians that these diseases
are not cured by the drug but by the physician,
that is by the personality of the physician, inasmuch
as through it he exerts a mental influence"
(p. 259). While in most of his writings Freud
emphasized the importance of the analyst's emotional neutrality (1912/1958; 1915/1958), accounts
written about his analyses (e.g., H.D., 1956;
Roazen, 1985; Wortis, 1954) reveal that in actual
practice he was not as neutral as he prescribed.
Carl Jung wrote: "It is in fact largely immaterial
what sort of techniques [the therapist] uses for
the point is not the technique but the person who
uses the technique . . . the personality and attitude
of the doctor are of supreme importance" (1934/
1964, pp. 159-160). Harry Guntrip (1969), a British
analyst from the object relations school, emphasizes
that the therapist must be a "real" person, a therapeutic good object, and that the technique of
psychoanalysis itself does not constitute the cure.
The therapist, in order to be effective, cannot be
afraid of a truly personal relationship with the
client; the therapist must be capable of intimacy.
For Greenson (1971) this also meant that the therapist must have the capacity for intimate knowledge
of himself or herself, and must be able to admit
to and own painful personal characteristics or behaviors. Greenson (1972) held that the therapist
must interact with the client as a fellow human
being, that there is a "real relationship" (p. 213)
which coexists with the transference or therapy
relationship. When the client experiences misfortunes, or makes progress in treatment, or when
the analyst makes mistakes, it is important for
the analyst to respond as a person. It is destructive
for the analyst (or therapist) to adopt a rigidly
objective stance in every instance of the client's
experience.
Greenson (1960) also believed that some therapists are inhibited in their ability to empathize;
those with chronic and generalized inhibitions have
a poor prognosis for being competent clinicians.
Silverman (1985) claims that the therapist must
be able to allow herself or himself to experience
a "regressive emotional reaction" (p. 179) and be
able to "drift freely" (p. 179) in response to the
The Person of the Therapist
client's productions. To allow this momentarily
egoless state, a therapist has to have a solidly
structured sense of self, or such an experience
could feel threatening and overwhelming. In this
egoless mode, the therapist is "plunged into the
world of objects" (Sartre, 1957, p. 40) and sets
aside the self.
In his classic text Listening with the Third Ear:
The Inner Experience of a Psychoanalyst (1948),
Theodor Reik also highlights the importance of
the therapist's being self-aware. The process of
giving permission to his or her own experience
of inner thoughts and feelings can lead the therapist
to deeper understanding of the self and thereby a
greater capacity to facilitate clients' self-awareness.
This "third ear" can capture clients' unspoken
thoughts and feelings, and it can be turned inward
to hear voices within the self that are usually
drowned out by conscious, rational thought. The
therapist attempts to recognize the meaning of
this "almost imperceptible, imponderable language" (Reik, 1948, p. 147), and this is only
possible by looking into oneself—a process that
can be described as "autohypnotic" (p. 171). The
therapist's self-observing and self-experiencing
process will involve acceptance of the "ego-horror"
(Reik, 1948, p. 174) as well as the ego-ideal: the
opposite extremes of psychic potentialities.
Acknowledgment of these potentialities, an inner
truthfulness, is essential for a clear understanding
of the capacities of the self and, by corollary, for
understanding the vicissitudes of clients' traumas
and capabilities.
The psychoanalytic position as reflected by these
writings holds that it is critical for the therapist
to be self-aware and self-accepting. There is no
requirement that the therapist be "perfectly analyzed" (Silverman, 1985, p. 175), or a paragon
of mental health (Raker, 1957; Wolstein, 1959);
rather, a deep commitment to the development of
the self is considered to be a prerequisite for effective functioning as a therapist. Clients presenting
to therapy place themselves and their mental health
in the trust of the therapist. Therapists who are
severely limited in their own personal resources
will have great difficulty attending to the needs
of their clients. In a number of training programs
and in psychoanalytic schools in particular, it is
a requirement of training for trainees to enter and
complete a personal analysis.
Milton Erickson, who started his professional
life as an analyst, developed his own approach
involving hypnosis. He claimed that hypnosis does
not hurt anyone but that the personality of the
hypnotist could be hurtful (Langton & Langton,
1983). Erickson encouraged therapists to vigorously
pursue training, supervision, and psychotherapy
to ensure personal development. He considered
the latter to be a cornerstone of the successful
practice of hypnosis. Erickson also emphasized
the importance of therapists' paying attention to
their own unconscious as a means of understanding
their clients' experience (Langton & Langton,
1983). Sheldon Cohen (1982), who uses both psychoanalytic and Ericksonian methods, points out
that Freud and Erickson shared the belief that the
therapist's personality was of primary importance
as the curative factor in therapy. In fact, Erickson's
own success as a therapist is attributed to the
personal power he exuded (Haley, 1982).
From the family systems perspective, Carl
Whitaker believes that very successful therapists
are able to be more fully themselves than their
clients dare to be. Whitaker (1982) also claims
that in the process of therapy, therapists must be
willing and able to allow an autohypnotic, trancelike state to occur in themselves. In this way, he
argues, therapists can be open to their own unconscious material as it relates to the client's issues.
Such openness can produce anxiety in the therapist.
From Whitaker we hear the same message that
Reik (1948) and Silverman (1985) communicate:
Therapists must know and trust that their own
sense of self will stay intact when allowing unconscious reactions to the client's material to wash
over them.
This position underscores the extreme importance of therapists' being well developed as persons
who will not be diminished or fragmented by
listening to and fully experiencing their own inner
messages. Therapists' interest in their personal
development is critical to their ability to assist
clients to change. A vital, creative therapist is
going to bring this vitality to his or her clinical
work, and the clinical work can in turn enhance
the therapist's process of self-discovery. The therapist's enthusiasm for personal growth will be
conveyed to the client, and this quality can serve
to influence the client's movement toward positive
change. Whitaker & Napier (1978) believe that
techniques can become formulas that rigidify a
therapist's stance; the most productive clinical
work occurs when the therapist is open to spontaneous, inventive methods that are expressions
of who the therapist is as a person. Whitaker
(1982) emphasizes this position by quoting Barbara
Betz: "The dynamics of psychotherapy are in the
person of the therapist" (p. 496).
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E. A. McConnaughy
Another family systems proponent, Murray
Bowen (1974), has spoken with admirable frankness about his own family of origin. His approach
as a clinician has interacted with his understanding
of himself within his many professional and personal relationship systems; personal insight and
learning have led to professional formulation which
in turn has produced further personal growth.
Minuchin & Fishman (1981) believe that it is
critical for the therapist to have a keen self-awareness regarding the range of levels of intimacy and
involvement he or she wants to have with clients.
Each therapist needs to determine a comfortable
level of intimacy that suits his or her individual
character. Appropriate therapeutic strategies are
those that are tailored to the therapist's unique
interpersonal manner. Minuchin (1974) suggests
that to facilitate "joining" the family, the therapist
"emphasizes the aspects of his personality and
experience that are syntonic with the family's"
(p. 91). Countertransference reactions of the family
therapist provide valuable information about pressures within the system; this view of countertransference phenomena is akin to that of the interpersonal dynamic therapy school (cf. Anchin
& Kiesler, 1982; Strupp & Binder, 1984): Rather
than keeping his or her responses in check, the
therapist allows reactions to surface and then uses
them to understand the entrenched, characteristic
patterns of interactions that occur in the client's
system. The therapist uses his or her personal
awareness to facilitate the client's self-discovery.
This process requires considerable interpersonal
skill and self-awareness because it involves addressing material that clients are reluctant to confront, and because it requires that the therapist be
able to access his or her reactions to clients on a
moment-to-moment basis.
The therapist uses herself or himself as a barometer of disturbances in the system, and, by
virtue of this intimate connection with the system,
the therapist can help to restructure the faulty
mechanisms. The experience of being able to become immersed in the client's dynamics requires
that the therapist have a strong "observing ego."
The demands of being sensitive to countertransference feelings requires that the therapist have a
well-developed sense of self. In this way, a therapist's openness to countertransference is much
like the risks of receptivity to unconscious processes
discussed earlier. Both events are stressful to the
therapist and can only be accommodated by therapists with a flexible character structure who can
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tolerate ambivalence and uncertainty.
From the beginning, the humanist movement
emphasized the importance of the therapist as a
person in the therapy enterprise. Self-understanding
in regard to basic personality functioning, emotional
patterns, and character strengths and limitations
are requisite for the successful therapist (Rogers,
1939). Rogers' classic work (1957) outlines the
"necessary and sufficient conditions of therapeutic
personality change" (p. 95). Three of those six
conditions relate to essential therapist characteristics: the capacity for genuineness, for caring,
and for empathy. The therapist should be a "congruent, genuine, integrated person" (p. 97); within
the relationship the therapist is "freely and deeply
himself, with his actual experience accurately
represented by his awareness of himself" (Rogers,
1957, p. 97).
Rogers (1957) clarifies that therapists do not
have to be perfectly well adjusted at all times. It
is imperative only that therapists be aware of their
own feelings and allow themselves to experience
those feelings during the therapy hour; therapists
must be true to their basic sense of self. What is
communicated to clients is therapists' solid
grounding in the self; the actual content of therapists' affects need not be shared. Therapists titrate
what is shared about their feelings based on what
is appropriate for the needs of the particular client.
The ability to assess what is to be shared with
clients and the timing of that sharing requires
considerable interpersonal skill and self-awareness.
Therapists need to determine how any communication might be received by the client. Corey
(1977) underlines the importance of the therapist's
willingness not to become a "finished product"
(p. 234); the openness to the struggle for personal
growth is part of the excitement of being a therapist.
Successful therapists develop unique and individual
styles that are tailored to their own personalities;
their therapy styles reflect their personal philosophies and life-styles.
Traditionally, behavioral theorists have deemphasized the role of the therapist's personal
characteristics in therapy. In practice, however,
many behaviorists believe that therapist qualities
are important. Arnold Lazarus (1985) has been
especially forthright in acknowledging that empathy, rapport, and identification are key elements
in good behavior therapy.
Psychotherapy Research
The cumulative results of psychotherapy research
The Person of the Therapist
indicate that there are essentially no differences
in effectiveness among therapies for most problems
(Luborsky et al., 1975; Sloane et al., 1975; Smith
et al., 1980). For the clinician and theoretician,
these research findings have an interesting implication: No one therapy approach is uniformly
superior. However, there is agreement that therapy
is more effective than no treatment (Luborsky et
al., 1975; Sloane etal., 1975; Smithetal., 1980):
We know that something is working. A reasonable
explanation for this finding is that it is the individual
therapist, regardless of school, who determines
the quality of the therapy. Within each school,
there are therapists who are highly developed as
persons, who are charismatic, and who can feel
comfortable with the intimacy of the therapy relationship. And within each school, there are therapists who are not introspective, who have not
grappled with their personal issues, who are interpersonally awkward, and who feel safer with
the emotional distance that acting a role provides.
The therapists within the schools are what is critical
to a therapy's success. It is possible that each
school has a within-group variance (determined
by qualities of the individual therapists) that is
greater than the between-group variance (determined by theoretical orientation), and that it is
not the techniques or therapy strategies per se that
are curative. The finding of no differences lends
itself to the thesis that the therapists themselves
as persons are more influential than their theoretical
orientation or technique.
Bergin (1963) offered a similar explanation of
the research findings. He suggested that the positive
effects of some therapists might be neutalized by
the negative impact of other therapists within the
group being studied. Bergin's claim was that the
effective therapists are those who have personality
characteristics and interpersonal skills that facilitate
a constructive therapy relationship; the techniques
they use assume a less important role. Koenig &
Masters (1965) conducted a study designed to test
the effects of therapists as well as therapy approaches. Each of seven therapists conducted three
types of treatments (systematic desensitization,
aversion therapy, and supportive counseling) for
subjects who were attempting to stop smoking.
The authors found that treatment success was significantly related to the therapists but unrelated
to technique. This finding underscores the claim
that the influence of individual therapists on treatment is greater than the effects of particular techniques. Based on his research findings, Strupp
(1958, 1959) concluded that the therapist's contribution is both personal and technical: "The personal contribution was seen as uppermost... in
the absence of a favorable emotional matrix, no
amount of expert technique could shift the psychodynamic balance in the direction of therapeutic
growth" (1959, p. 349).
Since the 1960s, the field has moved away from
an emphasis on the therapist's contribution. Some
of the research findings on specific therapist behaviors have been equivocal (see reviews by Beutler
et al., 1986; Parloff et al., 1978), and this has
led to discouragement. Other studies have suggested that therapist "traits" are situationally or
patient determined (Houts et al., 1969; Moos &
Macintosh, 1970; Van der Veen, 1965). Although
there have been and still are questions about the
adequacy and representativeness of these studies,
there was a loss of interest in viewing the role of
the therapist's personal qualities in psychotherapy
as primary.
The movement away from an emphasis on the
therapist's contribution does not mean that this
has been infertile ground, however. In fact, a
recent review of the literature by Beutler et al.
(1986) suggests that research on therapist variables
has yielded very fruitful results. Of particular interest are the findings related to two themes: 1)
It is important for the therapist to have a sense
of personal well-being; and 2) therapists' styles
of interpersonal influence are differentially effective. Additionally, therapists' ability to facilitate
affective expression, flexibility, and genuineness
are other important factors in psychotherapy.
Therapist Well-Being
Research on therapist well-being has produced
relatively consistent results, indicating that therapists' personality functioning does affect the
psychotherapy (Beutler et al., 1986). Garfield &
Bergin (1971) examined MMPI profiles of therapists and found that the therapists who were lowest
in emotional disturbance were more effective in
decreasing depression and defensiveness among
their clients than were more disturbed therapists.
Furthermore, therapist personality integration has
been found to be significantly associated with client
willingness to remain in treatment (Anchor, 1977).
Along similar lines, Holt & Luborsky (1958) have
found that competent therapists have greater
"breadth and differentiation" (p. 278) than less
successful therapists. Moreover, the overall emotional climate of therapy was found to be affected
307
E. A. McConnaughy
by the personality styles (i.e., "expressive" or
"repressive") of therapists (Wogan, 1970). Expressive therapists were characteristically weUliked
and felt less defensive about expressing dysphoria;
they were found to be more effective clinicians.
Therapists who were less effective were less wellliked and had a tendency to deny negative personality characteristics (Wogan, 1970).
When therapists are not experiencing a sense
of well-being and equanimity, their work seems
to suffer. Cutler (1958) found that therapists' reactions to clients were affected by the therapists'
own conflict areas. When clients' material activated
therapists' conflicts, therapists' responses tended
to be oriented toward maintaining their own emotional equilibrium. When the clients' material was
less conflictual for therapists, the therapists were
more able to respond in ways that facilitated the
clients' growth. A study by Donner & Schonfield
(1975) revealed that student therapists who were
characterized by high conflict levels tended to
respond with more anxiety to clients' depressive
statements than therapists with low conflict levels.
Therapists responding to surveys have reported
that their personal therapy (Buckley et al., 1981;
Prochaska & Norcross, 1983) and their work as
therapists (Farber, 1983) enhance their self-esteem
and their functioning.
Therapist Interpersonal Influence
Fairly consistent results have also obtained from
research on therapists' interpersonal influence
(Beutler et al., 1986). Expertness, trustworthiness,
attractiveness, and credibility are frequently considered to be the most salient characteristics of
therapist persuasion. Therapist credibility was
found to be positively associated with client improvement (Beutler et al., 1975). LaCrosse (1980)
found that therapist attractiveness, trustworthiness,
and expertness together accounted for 35% of the
outcome variance. A number of other studies (e.g.,
Childress & Gillis, 1977; Heppner & Dixon, 1981;
Heppner & Heesacker, 1982; Goldstein, 1971)
demonstrated the impact of therapist interpersonal
influence variables on psychotherapy outcome; in
fact, Beutler et al. (1986) found only one study
(Merluzzi et al., 1977) that produced a nonsignificant effect for therapist interpersonal influence.
Fiedler (1950) suggested that the therapy relationship can be seen as a variation of good interpersonal relationships in general. Those who
are influential people are likely to be more effective,
influential therapists.
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Therapist Facilitation of Affective Expression
Another therapist personality characteristic that
has been investigated and demonstrates a consistency of results is therapists' ability to tolerate
clients' affects. Ehrlich et al. (1979) and Wenegrat
(1976) found that therapists who used statements
which emphasized clients' affects were more highly
rated by their clients on variables such as therapist
attractiveness, expertness, trustworthiness, and
empathy. In a series of studies, Mitchell and his
colleagues (Berenson et al., 1968a; Berenson et
al., 19686; Mitchell & Hall, 1971) found that
effective therapists confronted and interpreted
clients' affects more frequently than less effective
therapists. Clients' progress in therapy appeared
to be adversely affected when their therapists were
conflicted about accepting the clients' expressions
of hostility (Bandura et al., 1960).
Greenberg & Dompierre (1981) demonstrated
that emotionally confrontive approaches facilitated
therapeutic process, conflict resolution, and client
awareness. Ricks (1974) contrasted two therapists
who responded differently to their clients' affects
and whose clients showed differential treatment
successes. "Supershrink" (Ricks, 1974, p. 275),
who demonstrated "an unusual openness to the
[clients'] feelings and unusual freedom from threat
in the presence of extreme love or extreme hostility"
(p. 286), was described as highly successful in
helping his clients live lives free of schizophrenia.
A comparison therapist, who "tended to take a
distant, cognitive attitude toward expressions of
feeling" (p. 287), appeared to have a destructive
effect; his clients were more likely to become
schizophrenic and show signs of poor social adjustment. Some of the research on facilitation of
client affect focuses on therapists' use of techniques. It could be argued that techniques designed
to elicit client affect are used differentially by
therapists depending on their comfort with their
own and others' affects.
Therapists' ability to be flexible in the use of
therapy techniques is an important therapist attribute
which has received increasing attention in the literature (Beutler et al., 1986). Therapists report
that treatment is enhanced when the therapeutic
approach is tailored to suit the unique needs of
individual clients (e.g., Garfield & Kurtz, 1977;
Norcross & Prochaska, 1983). Prochaska's transtheoretical therapy model (1984) attempts to outline
systematically the therapy approaches which are
most appropriate for different clients along par-
The Person of the Therapist
ticular dimensions, for instance, clients' stages
of change (McConnaughy et al., 1983; McConnaughy et al., 1986£) and clients' problem levels
(Norcross et al., 1985). In sum, it is important
that therapists be flexible as persons so that they
are able to adequately implement a variety of
therapeutic strategies.
Surveys of psychotherapy clients reveal that the
personal characteristics of the therapist play a central role in creating a positive therapeutic alliance;
technique factors seem relatively unimportant to
clients. Strupp et al. (1969) found that a "good"
therapist was seen as "keenly attentive . . . having
a manner that patients experienced as natural and
unstudied, saying or doing nothing that decreased
the patient's self-respect. . . and leaving no doubt
about his 'real' feelings" (p. 80). Grunebaum
(1983) surveyed psychotherapists who themselves
had sought therapy. The therapist-patients selected
their own therapists based largely on the therapists'
personal characteristics; technical competency
alone was not sufficient. In Grunebaum's study
(1983), therapists were highly prized for their
genuineness and for the respect they showed for
their clients. These qualities resonate with Rogers
(1957) "necessary and sufficient conditions" for
change.
In conclusion, therapist well-being and social
influence are among the "most promising," consistently reported, "robust and meaningful" therapist characteristics, and they are "deserving of
continuing attention, both clinically and empirically" (Beutler et al., 1986). Therapists' flexibility,
genuineness, respectfulness, and ability to deal
effectively with affect are other valued therapist
qualities; they reflect the therapists' well-being,
sense of self, interpersonal comfort, and skill.
One caution must be stated: It would be an oversimplification to suggest that any one therapist
variable would be uniformly beneficial and solely
responsible for therapy process and outcome.
Psychotherapy is a complex medium; it is reactive
to the mutative effects of particular clients, relationships, and settings. However, this precaution
does not militate against the position that the person
of the therapist determines the quality of the treatment that is offered to a client. The research results
certainly lend credence to this claim.
Implications
The convergence of clinical and empirical evidence points to the critical importance of the therapist's character and interpersonal style for therapy
process and outcome. The clinical and theoretical
literature highlights the relevance of the therapist's
personal contribution to therapy process. The research literature underscores that therapist wellbeing and interpersonal skill contribute positively
to the desired outcome of beneficial change for
clients. Such a consensus suggests that this phenomenon should be given serious attention in psychotherapy training, research, and practice.
Most experienced practitioners are aware that
the influence they exert as persons is beyond the
scope of the techniques they may utilize. However,
while the technical procedures a therapist selects
may reflect the personality characteristics of the
therapist, it is critical that training include acquisition of technical skills and knowledge of patient psychopathology so that therapy be tailored
to the individual clients' needs and issues. In the
broadest terms, clients who are troubled by affects
or their inability to experience affect are helped
by techniques aimed at facilitating the understanding and appropriate expression of affect.
Clients whose cognitions are self-defeating are
helped by approaches that clarify and reframe
their troublesome cognitions. And clients who
engage in problematic behaviors are helped when
they can examine old patterns and practice new
approaches. Virtually all therapy schools attempt
to modify maladaptive affects, behaviors, and
cognitions.
Each school has different technical operations,1
but within each school, therapists perform the
operations in more or less idiosyncratic ways. It
is essential to clarify that techniques (and theoretical
orientations) are selected by individual therapists
because of their personal appeal, and in most
clinical settings the techniques are modified to
suit the personal style of the therapist. The quality
of the practice is determined by the personal qualities of the therapist and not by the rote enactment
of particular rituals or a rigidly structured set of
techniques. The techniques become a manifestation
of the character or person of the therapist. Experimental evidence suggests that "the therapist's
unconscious attitudes may subtly color his 'technical' thinking about a case, his diagnostic formulations, prognostic estimates, therapeutic plans,
1
Or, according to Goldfried (1986), the same therapy strategies are assigned different names by different schools, and
these names reflect jargon that is culture-syntonic for a given
school and culture-dystonic for a competing school.
309
E. A. McConnaughy
and goals, and ultimately the character of his
communications" (Strupp, 1959, p. 357).
Technique is an important expression of the
therapist, and because no technique has been shown
to be uniformly superior, it is beneficial to assist
therapists in training to discover those techniques
that are the best expressions of their individual
selves. Effective supervisors assist trainees to
sample a variety of procedures, either within a
theoretical orientation or among a number of different schools, so that when training is completed
the new therapist has a sound basis for developing
his or her unique style. Beginning therapists require
more direction and are helped by specific instruction
about the performance of therapy-appropriate behaviors. Advanced students need supervisors who
can facilitate the students' own self-discovery.
Training is optimal when supervisors are flexible
in the approaches they take with individual trainees.
In this way, successful supervisors are like the
effective therapists who are sensitive and responsive
to the unique requirements of their clients.
It is expected that while they are learning, therapists in training at all levels are not always clear
whether a particular technique is comfortable for
them. And the degree of comfort is often tied to
the therapist's level of personal and professional
development at any given time. Until the learning
becomes assimilated into the therapist's repertoire,
the implementation of techniques feels like a mechanical performance. The methodical and persistent attention to the details of performance, by
design, produce self-consciousness. This experience is not unique to learning psychotherapy.
Therapists in training have varying degrees of
tolerance for this uncomfortable phase, and this
impacts on their ability to be open and take risks
in the course of their explorations.
Supervisors are involved in evaluation of the
supervisees' strengths and limitations, and, except
in instances where there is serious cause for concern, learning is enhanced when feedback is given
in an atmosphere of mutual discovery and exploration. It is important that training assist therapists
to know themselves well—their strengths, their
conflicts, and the individual issues that get activated
in therapy relationships (counter-transference). An
emphasis is placed on helping the therapist to
maximize his or her personal strengths and resources and to be aware of vulnerable areas that
need be within the therapist's awareness. According
to Strupp (1959), "the extent that [the therapist]
is unaware of the ways in which he influences
310
the interpersonal process, he is at the mercy of
unknown forces and may merely observe and record
events which his very operations have brought
about" (p. 350). Technical skills and deficiencies
need also be addressed. Trainees learn a great
deal from supervisors who are themselves welldeveloped as persons and who have interpersonal
skills that facilitate learning. Much of what has
been said about the impact of the therapist's character and personality on therapy applies also to
the effect of the supervisor's style on the training
experience.
To ensure that each client is receiving quality
care, it is important for each therapist to have a
theory of change. Many clinicians claim they have
no theory, they simply work "intuitively." While
it is important for therapists to listen to their inner
voices when responding to clients, theory (whether
traditional or individualistic) is necessary for therapists. Training in and enthusiasm for a special
theory can increase the effectiveness of therapists,
in contrast to nonprofessionals who lack belief in
a coherent system or rationale (Frank, 1973). A
theory must have personal appeal. Some experienced therapists choose to follow a traditional
theoretical approach that offers history, culture,
and methods that have been established over years
of practice, while others formulate their own integration of various perspectives. Needless to say,
there is no one correct way to select a beneficial
theoretical orientation. No matter which approach
therapists adopt, they use therapy strategies in
ways that suit their individual styles. Therapists
need to continually modify their theories based
on new clinical input. The successful adaptation
or the formulation of a new theory of therapy
results from the individual therapist's developing
and perfecting his or her own approach. Experienced therapists who are long out of training do
well to continually assess their theories, their
strategies, and themselves.
It is essential that therapists be aware of the
types of clinical populations they are effective in
working with. The individual client will provide
the most important modulating effect on the therapist's effort and consequently on the success of
the treatment (Strupp, 1978). Empirical and clinical
evidence suggests that therapists who are able to
maintain their emotional equilibrium in therapeutic
relationships are less changed by the reactions of
their clients and are more consistent in their responses to and treatment of clients (cf. Holt &
Luborsky, 1958; McConnaughy et al., 1986a;
The Person of the Therapist
Ricks, 1974). For a beneficial relationship to develop, there has to be a match between the client's
needs and interpersonal style and the style of the
therapist. Some therapists, because of who they
are and how they relate to others, will be able to
successfully match with a wide range of clients.
Other therapists will encounter fewer clients who
can work well with them. The therapeutic relationship will lend itself to the healing process
through this match; in this way, the relationship
becomes the crucible for change. It is important
for therapists to be flexible in the approaches they
use with clients. Treatments useful in one area of
human disturbance are often found to be of less
value for other problem areas. Continued supervision or consultation with colleagues provides
feedback about the therapist's limits and the clients'
needs, and offers an opportunity to assess which
clients may not be responding to treatment and
would therefore be considered for referral.
The therapist's experience and confidence can
provide comfort and inspiration to the client during
painful, confusing times when the client is trying
to learn new ways of being in the world. The
therapist's belief in the human capacity for change
and the therapist's trust in the efficacy of psychotherapy in contributing to change will do much
to help the client feel it is safe to experience the
pain and confusion that are inherent in personality
change. It is through formal training and the practice
of therapy, and through their own efforts toward
personal development as well, that therapists learn
to believe in themselves enough to be able to
function as effective models of identification for
their clients.
Research on therapist variables has not been
an area of emphasis in the last decade (Beutler et
al., 1986). Stiles et al. (1986) contend that the
hope for finding a common configuration of therapist attributes and behaviors has faded. A possible
explanation for the equivocal findings is that many
of the studies of therapist attributes focused on
specific therapist behaviors. Although some of
these behaviors may be the observable representations of deeper therapist personality characteristics, it appears that a majority of studies did not
move beyond the surface level. There are therapists,
for example, who can perform all of the behavioral
components that comprise empathic listening (e.g.,
eye contact, forward leaning, head nodding, verbal
utterances indicating attunement), and yet unless
they actually experience an empathic reaction to
the client, the client will not feel heard. The ob-
servable behaviors, at least at the macroscopic
level, do not always completely describe the therapist's emotional involvement and the affective
and perceptive interchanges that take place between
therapist and client. We need new methodologies
to be able to discern these clinically palpable but
empirically elusive phenomena.
Several alternative modes of investigation suggest themselves in place of the placebo and competing models paradigms. Studies of "successful"
therapists during "good" hours (e.g., Goldfried,
1986) and studies examining therapy process at
the microscopic level (e.g., Henry et al., 1986)
are important areas of investigation because they
offer in-depth examinations of the process of therapeutic change. The clinical richness that is often
sacrificed in more traditional studies is accessible
in these designs. Studies examining the same therapists using different types of therapy approaches
(e.g., Koenig & Masters, 1965), and intensive
studies of the differences among a small number
of therapists (e.g., McConnaughy et al., 1986a;
Ricks, 1974) are important but neglected areas of
research. Studies such as these could prove especially fruitful in clarifying the personal contribution of therapists. Cutler's (1958) approach of
studying therapists' conflict areas and comparing
these with process ratings of therapy sessions has
not been pursued for almost thirty years. There
are good reasons why studies of this nature are
rare. Therapists who allow their work to be scrutinized are taking personal and professional risks;
it is even riskier when therapists agree to report
conflict areas and personality patterns. However,
these factors do not militate against doing more
intensive studies of therapists. There continue to
be therapists who are courageous enough to take
those risks. It is incumbent upon us as researchers
to develop a style of reporting results which is
constructive and easily heard. Studies of therapist
character, personal development, and interpersonal
style are essential if we are to understand how it
is that the personality of the therapist makes its
imprint. The difficulty of the task before us does
not suggest its dismissal or its relegation to obscurity. Indeed, what is called for is a renewed
and invigorated attempt to learn about and understand this critical phenomenon.
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