The purpose of this study is to explore clients and therapists’ experiences of gender within the therapeutic relationship and how they affect overall treatment effectiveness and duration. Because gender issues create obstacles or advance progress, this paper discusses how gender differences affect the formation of the therapeutic relationship and how these effects alter therapy outcome. Clients expect male therapists to be more controlling in therapy, while they perceive females to more supportive; therefore, seeing a male therapist is likely to limit initial disclosures by clients. It has also been determined that a therapist’s credibility can be reduced based on their gender’s accepted roles. From a therapist’s standpoint, gender has been shown to alter their expectations in clients. Female therapists have been found to be more tolerant and accepting during the therapeutic process- displaying more unconditional positive regard. However, male therapists show more sensitivity to gender regarding their behavior and outlook towards clients; they’re more critical of females and hold males to higher expectations. Both client and therapist perceptions of gender have been shown to hinder the interaction between client and therapist; however, little focus has been given to how these perceptions play out in the development of a therapeutic alliance. Studies have shown such an alliance to be essential to the effectiveness of psychotherapy. Therefore, it is believed gender affects more than just client and therapist relations, but also has the ability to affect therapy diagnosis, treatment selection, length of treatment, and therapeutic outcome.
Social influence is when an individual’s thoughts or actions are affected by other people, real or imagined. This type of influence takes on many forms and can be seen in areas of socialization, peer pressure, obedience, persuasion, sales, and marketing (Carli, 2001). Although we rarely like to admit to it, gender plays a significant role in social influence. When judging someone’s competence, gender often takes front stage; however, we like to presume it is not a deciding factor. In the realm of psychotherapy, this type of social influence is often overlooked; therefore, important benefits or limitations to therapy go unnoticed (Jones & Zoppel, 1982).
Psychotherapy has been referred to as the treatment of emotional and personality problems and disorders by psychological means. An important factor for most orientations within clinical psychology is the client-therapist relationship, with an obvious component of this relationship being the gender of the therapist and client (Gehart & Lyle, 2001). In the understanding and practice of psychotherapy, gender is an important but neglected variable. Gender can influence the client’s choice of therapist, the rapport between them, the sequence and material presented for the diagnosis, and the length and final outcome of treatment (Gehart & Lyle, 2001). Prescriptive norms, such as warmth and communality, often are attributed to females whereas males are seen as authoritarian figures (Carli, 1999). Norms associated with gender play a major role in determining the strength of therapeutic relationships as well as treatment outcomes.
Patients give many reasons for their choice of therapist. These reasons are often based on stereotyped views such as that men tend to perpetuate leadership values, or that women provide more nurturing kinds of skills (Carli, 2001). Patients express that they feel more comfortable in choosing their therapist based on these traits. This method of choice can also prove beneficial to therapists as it facilitates a more prompt positive therapeutic alliance (Gehart & Lyle, 2001). Selection of therapist’s gender does not only apply to patients, some therapists also make recommendations following these gender stereotypes (Gehart & Lyle, 2001). For example, adolescents are often confronted with confusing sexual issues that can be pressing and embarrassing; therefore some clinicians suggest that they seek a therapist of the same sex for treatment in order to keep gender conflicts at a minimum.
Despite gender’s obvious importance in social interaction, sex of patient and therapist has been looked at sparingly in psychotherapy research until the past two decades (Felton, 1986). In regards to gender influences within therapy, previous studies presented a somewhat ambiguous picture. Scher (1975) examined therapy satisfaction and symptom relief in 36 college students at a university counseling center. This study found no important differences associated with sex of client or therapist in the students’ ratings of therapy. However, an investigation by Persons et al. (1974) that also involved both male and female college students at a counseling center, found conflicting results. Their study determined those matching in gender with their therapist listed more characteristics of their therapist as helpful. Similarly, Howard et al. (1970) reported that women seen for outpatient therapy by a female therapist reported more positive experiences and expressed greater satisfaction with treatment than those seen by male therapists. Male therapists typically reported seeing more unpleasant emotions in their female clients than did their female counterparts. It was also stated that female therapists were more successful with young, single women who were depressed.
Recently, therapists are now slowly granting more attention to the consequences of gender differences. Once believed to be minimal or unimportant in the overall success of the therapeutic relationship, more and more female clinicians entering the field has warranted a closer look at both the gender of therapist and patient (Felton, 1986). Questions of whether a male therapist can really understand his female patient are still up for debate (Felton, 1986). Although, Gehart and Lyle (2001) state the most appropriate response to these questions is that no matter how experience a clinician is, there are still occasions in treatment when issues of gender create obstacles for both client and therapist. In psychotherapy, therapists convey important values to clients through their selection of the material presented to question or to comment on, the timing of their interpretations, and by their affective reactions towards the client’s responses. Obstacles are created when a therapist differing in gender views a client’s life experiences differently, especially if these experiences are gender specific (Shapiro, 1993).
As noted, along with gender norms come preconceptions, creating ease or strain on a therapist’s attempt to build rapport, which influences their ability to affect therapy’s length and/or effectiveness. Therapists often face situations where third-party payers restrict the amount of treatment their clients are allowed to seek; therefore, they are compelled to move quickly in the therapeutic process (Anderson & Lambert, 2001). In the realm of psychotherapy, gender’s role is in need of further exploration to determine whether it presents barriers that interfere with therapy, especially in terms of the therapeutic relationship. Past research has found that men often exert more motivation than women giving them the ability to persuade others in taking action, an often important step in psychotherapy (Farber & Geller, 1994). Critical factors important to patients have also been studied and how they aid or prevent relationships from forming (Farber & Geller, 1994). These studies concluded that differences exist among compliance between genders. Therefore, it is expected that matching a therapist in gender will form a more prompt and effective therapeutic alliance regardless of diagnosis, resulting in a more efficient psychotherapeutic process. Identifying obstacles and/or assets gender may pose is crucial in being able to foster a stronger therapeutic alliance to allow therapy to move at a timelier pace.
Experience of Gender in Therapeutic Relationships
Among clients currently in psychotherapy, their reasons for choosing their therapist were quite vague as previous research had documented. Pikus and Heavey (1996) assessed therapy preferences for 116 clients ranging in age from 18 to 69. They found client preferences for therapist’s gender either to have none, preferring to match, or preferring solely female therapists. Reasons for these preferences were also tallied and determined that most clients based their preferences on understanding and being able to relate to their therapist in gender expectations. Those preferring female therapists; however, tended to seek comfort more so than association.
Social influence research has focused on client perceptions of their therapist’s characteristics of expertness, trustworthiness, and gender identity to determine exactly why clients hold preferences in gender. Feldstein (1979) was one of the first to study whether sex or gender role identity (e.g. level of masculinity or femininity) is a critical factor in the therapeutic relationship. Eighty-four undergraduate college students were randomly assigned to one of four treatment groups where they took part in a counseling interview. These four groups were determined by their counselor’s gender identity: Masculine male, masculine female, feminine female, and feminine male. The study concluded that male clients disclosed more to feminine female therapists compared to more masculine therapists. Female clients followed the same pattern in regards to male therapists, with feminine male therapists receiving more disclosure. The masculine characteristics were projected as more assertive, controlled, and action oriented, whereas feminine therapists were projected as more supportive and emotional. Therefore, clients that perceived their therapist to be more empathic were more initially active in the therapeutic process, facilitating a strong therapeutic relationship much sooner than those who perceived their therapist to be more direct.
To determine how the therapist’s credibility might be affected by such perceptions, Lee et al. (1985) determined it was positively correlated with gender accepted roles. For example, male therapists gained credibility if a client’s presenting concern dealt with career planning, but would lose credibility if the concern was child rearing. Lee et al. (1985) had 47 graduate counseling students conduct a 20 minute interview with a volunteer, then asked them each to complete a behavior rating form on the interview process. They found a significant three-way interaction among therapist sex, client concern, and client sex. It was concluded therapists received more credibility from same-sex subjects on relationships (e.g. romantic and paternal) and from opposite-sex subjects on vocational concerns.
Very few studies have looked at client perceptions of gender after treatment has been completed. Henderson and Lyddon (1997), in an attempt to increase external validity, assessed gender role perceptions after clients were discharged from treatment. They took 57 volunteers seeking therapy and asked them to complete a demographic and an attitudes towards women form preceding therapy. At therapy completion they completed a therapist rating form. As seen in previous studies, female clients often rated their therapists more positively than did males; however, female clients disclosed they were more open to change regardless of their therapist’s gender. These findings suggest rapport and relationship building may need to be more of a priority with male clients. The positive correlation calculated between gender role attitudes and perception of female therapists indicates liberal views of women in society may lead to such positive ratings of female therapists. This being true, being able to assess for such views in intake settings raises possible implications in client matching (Henderson & Lyddon, 1997). For example, clients possessing less stereotypical views of women will bond well with either male or female therapists. On the other hand, female therapists would best be suited for those holding more strict views of women and may also need to spend more time in the initial stages of therapy to further strengthen the relationship.
Being able to establish rapport between client and therapist allows for a trusting and healthy relationship to form. A crucial part of this relationship is the client’s use of cognitive-affective representations of their therapist (Farber & Geller, 1994). Farber and Geller (1994) looked at how the gender of the therapist influenced the nature of a patient’s internalized representations of their therapist and the corresponding relationship. Using the Therapist Representation Inventory (TRI), patients indicated they relied in varying proportions on words, sounds, odors, body movements, and somatic representations to construct a relationship with their therapist. In addition, self-perceived improvement in psychotherapy was positively and significantly correlated with the clients who felt more connected to their therapist, thus feeling a strong therapeutic relationship. Therefore, being aware of gender and other outside factors can be extremely important in facilitating a productive relationship. As a therapist, being aware of how one reacts (e.g., voice, body, etc.) to those opposite in gender can make all the difference in building a prompt, lasting rapport to help in aiding you and your client’s therapeutic goals.
Therapist Perspective of Gender
From the therapist’s side, the importance of counter-transference has long been recognized. Male and female therapists have been found to hold differing expectations amongst their clients based on their gender. Identifying these expectations is not just important in terms of transference, but also in terms of diagnosis and treatment selection. Jones and Zoppel (1982) expected male therapists would hold males to higher expectations and be more judgmental with females, thus increasing their likeliness to diagnose females and demand more of male clients. To further test this hypothesis, they asked therapists to complete three inventories measuring therapy outcome, therapeutic process, and adjective use during sessions on 160 former clients. Results concluded male therapists to endorse less socially desirable adjectives in describing clients, particularly female clients. It was also determined that female therapists were more tolerant and accepting during the therapeutic process regardless of client gender- displaying more unconditional positive regard. Thus male therapists tend to be more gender sensitive regarding their behavior and expectations towards clients (Jones & Zoppel, 1982).
Within social science research a lot has been said about the development of males and females. It has been posited that each gender is socialized differently to the norms of a specific society. For example, females are taught important values such as empathic attachment that urges them to use expressive functions. On the other hand, males are encouraged to separate themselves from such feelings and to look at things from a more functional viewpoint. Therefore, female therapists are seen to encourage expression and possess a higher tolerance for developmentally earlier needs, wishes, and feelings. In contrast, male therapists tend to work in the here and now with their clients and view female clients as “sicker” than their male clients (Korner & Goldberg, 1996). Korner and Goldberg (1996) studied this potential gender bias within therapy by asking 91 therapists to give their thoughts concerning treatment on male and female client vignettes. Both male and female therapists felt female clients needed more support and understanding rather than action and tolerance. It was suggested that male therapists appear to adjust their therapeutic approach the greatest in an attempt to implement change more quickly. That being said, male therapists look to gender expectations as a means to alter their approach to align with their client, while female therapists consistently value encouragement over accomplishment (Korner & Goldberg, 1997).
Conversation is a key mechanism in psychotherapy and varies between each therapist and their clients (Zimmerman & Murphy, 1997). If gender results in different responses within these exchanges, a possibility because gender influences conversation, therapists could create inequality rather than change. A study by Zimmerman and Murphy (1997) evaluated a component of such conversations. They examined therapists’ interruptions during family therapy, to see if women and men clients were treated differently. Their study used gender of the therapist as an interaction effect in regards to previous research suggesting gender has a significant consequence to the therapy dialogue. Results found male therapists to describe more problems in female clients than did their female counterparts. Male therapists were also seen to portray clients in a more negative light. However, the therapist’s gender was not determined to play a role in the number of therapist interruptions during therapy. Nonetheless, female clients were observed to be interrupted more often than male clients. Depending on the therapist’s view of the client’s gender, interruptions could be being used or viewed as a power tactic. It is important to consider that therapists may use such tactics as a result of their own socialization. Therapists may simply interrupt women clients more, simply because it is a common feature of conversation (Zimmerman & Murphy, 1997). .
Previous reviews of the literature have queried whether clinician characteristics such as masculinity, feminism, attitudes toward different genders, race, and status level may interact with the sex of clinician in predicting the process and outcome of therapy with patients (Berstein & Lecomte, 1982). A study by Berstein and Lecomte (1982) attempted to dispute that client gender significantly affects therapist expectations. They explored the relationship between therapists’ expectancies and gender, profession, and training level variables. Results of their study indicated that in some cases the therapist’s level of training and area of specialization were more important than client gender in determining therapists’ expectancies along diagnostic, prognostic, and process dimensions. These findings suggest that in certain situations gender of the client may become irrelevant with increased awareness and experience on the part of the therapist (Berstein & Lecomte, 1982).
Importance of the Therapeutic Relationship
Characteristics of a Productive Therapeutic Relationship
The therapeutic relationship is an encompassing term usually associated with psychotherapy. This relationship emphasizes the collaborative nature of an alliance between therapist and client (Horvath & Luborsky, 1993). Such an alliance incorporates client preferences and goals into treatment which in turn allows the therapist to establish methods for accomplishing those goals. The therapeutic relationship requires a therapist to listen and assess their clients without judgment. Throughout the literature, this relationship has been labeled as the actual treatment in psychotherapy and that without this positive alliance there is unlikely to be any progress. Nonetheless, even though it is considered to be an important component to therapy, a positive therapeutic relationship is often overlooked in predicting a client’s response to an intervention.
A crucial part of the therapeutic relationships is the client’s perception of the therapist. Client ratings are the most consistent predictor of client improvement (Lambert & Barley, 2001). If in developing a relationship a therapist fails to gain the client’s trust in regards to his or her abilities to help them change, the client is likely to resist treatment. Lambert and Barley’s (2001) summary of the literature found strong relationships to be documented as effective predictors for positive outcomes in all methods of treatment, and with various types of clients. They also state a strong therapist-client relationship can often be established quickly. In the literature, it was also determined that self-awareness has proven to be a positive factor in developing a strong alliance. Through self-awareness therapists must practice active listening skills with their clients and monitoring of their own responses towards them (Lambert & Barley, 2001). This characteristic is especially important in regards to gender. With the therapist’s perception of gender able to dictate compliance and trust, therapists must be aware of their biases to facilitate a positive alliance.
In regards to family members of clients, the therapeutic relationship can also hinge on how the therapist maintains a working partnership with client associates. (Mahaffeny & Granello, 2007). Family members can represent an important factor regarding treatment success and sometimes the relationship with family members is just as important as the one with the client (Mahaffeny & Granello, 2007). These individuals are seen to be a great influence on the client, and if a positive alliance is not made between them and the therapist, it can negatively impact treatment, even if a strong alliance exists with the client (Mahaffeny & Granello, 2007). Therefore, a therapist needs not only to consider their gender expectations towards their clients, but also acquaintances of them as these same expectations hold the ability to affect these relationships as well.
Research has shown and many agree that the therapeutic relationship is a necessity for successful treatment. Nonetheless, consensus has yet to be reached on a definition of such a relationship, nor on its fundamental components. Kolden et al. (1994) believe two essential ingredients needed to build a strong working relationship between client and therapist are empathic resonance and mutual affirmation. Empathic resonance refers to reciprocal understanding between the client and therapist regarding emotions and/or thoughts. As for mutual affirmation, therapists need to practice respect and affective attachment with their clients in order to induce reciprocation, which is needed to achieve compliance and trust. The presence of hope relayed by a therapist has also shown to make a significant difference in how people deal with stress, difficulty, and problems. It has been shown time after time, especially in the literature pertaining to those with co-occurring disorders, that hope is essential to successful treatment (Kolden et al., 1994).
Building an effective therapeutic relationship goes beyond therapists’ actions in sessions. The contributions of clinicians are very important to the foundation and maintenance of a positive therapeutic relationship. However, client contributions are just as important (Gelso & Carter, 1994). Clients have to present with the willingness to participate and to be productive in reaching their goals set forth in therapy to develop a sound working alliance. This may sound like common sense, but such client traits are often looked at in terms of therapy success and not the relationship. A recent major review by Gelso and Carter (1994) found client intentions crucial to how quickly an alliance is established. The more clients understand psychotherapy and what is needed in a therapeutic relationship the more compliant and open they are within sessions. To further facilitate client intentions, practices such as self-exploration and the experiencing of affect appear to help clients disclose their true reasons for seeking therapy. Gelso and Carter (1994) also hypothesized that such actions allow clients to find deeper meaning to their problems and become more aware of the changes that they are making, thus strengthening their belief in therapy and therapist. In their review, client involvement also proved to be just as important to the therapeutic alliance as therapist’s empathy and support. With those characteristics is mind, therapists need to be aware of when they need to shift their focus from clinical problems to the client’s therapy expectations in order to strengthen their understanding throughout treatment and thus collaboration (Gelso & Carter, 1994).
Incremental success, along with some of the traits just mentioned are not the sole characteristics needed to create a quality therapeutic relationship. Several studies have investigated beyond what makes a strong therapy alliance by turning the focus on when such an alliance needs to be formed. Mohl et al. (1991) studied the impact a therapeutic relationship established early on in therapy would have on treatment outcome. They took 96 prospective therapy clients and asked them to take part in an intake session, afterwards they were administered the inventories concerning their alliance with the interviewer. It was determined that the sooner a strong alliance was formed between therapist and client, the more efficient and successful therapy interventions would be in therapy. These findings not only highlight the importance of being empathic and assertive, but that the development of a positive relationship is critical from the onset of therapy. Mohl et al. (1991) went on to call this critical time period a “window of opportunity” to create a viable and working alliance early on in therapy session with clients to enhance treatment as well as prevent clients from ending therapy prematurely. Therefore, therapists not only need to be aware of themselves and their practices in therapy, but need to be attentive to the feel of their environment with their clients early, in order to address these apparent difficulties quickly so that an effective relationship can foster sooner than later.
Technique or Relationship?
One of the most important questions asked about psychotherapy is what makes it work. Researchers have studied numerous facets to the psychotherapy process searching for the key ingredients that lead to successful treatment and therapeutic change. The answers, however, have long been debated in the literature, with much of the focus centering on two primary components thought to result in effective treatment: therapeutic techniques and the therapeutic relationship (Goldfried & Davila, 2005). Instead of addressing the therapeutic relationship and techniques, researchers have often studied them separately. By pitting one against the other and searching for results in therapeutic change, research is fostering the idea that either technique or relationship holds the most responsibility for change.
Previous research has studied the characteristics of a productive therapeutic relationship as well as the effectiveness of therapeutic techniques; however, continuing to focus on them separately overlooks the fact that they may need each other. Goldfried and Davila (2005) depicted the relationship between client and therapist as a necessary part to a machine that works with therapy techniques to bring about positive change. They further state that techniques used by therapists, specifically their timing, further strengthens therapeutic relationships.
The concept that both the therapeutic relationship and technique play a vital role in the change process is further illustrated in a study by Persons and Burns (1985). They studied the intervention of challenging automatic thoughts associated with depressed mood. These interventions were carried out in naturalistic settings and were shown to improve overall mood; however, mood was further improved by the quality of the therapeutic relationship. Persons and Burn’s (1985) findings concluded the therapist’s relationship with their client had just as much of a positive effect as the therapy technique employed. A second study supported their findings by examining clients’ perceptions of their therapist. In this case, treatment interventions for depression were again studied, but this time the client’s perception of therapist empathy was found to positively affect outcome along with compliance (Burns & Nolen-Hoeksema, 1992).
The role of the relationship in the effectiveness of technique has been clearly illustrated and even though select researchers continue to examine them apart, consistent data has yet to come forth and prove that one can exist without the other. Castonguay et al. (1996) further supports this stance by examining interventions set to address a client’s thoughts and feelings. They examined 30 depressed individuals who were receiving cognitive therapy and found that when a strain (e.g., hostility towards therapist) was placed on the relationship between client and therapist that techniques alone resulted in negative outcomes. Therefore, psychotherapeutic techniques may have the support of empirical data, but without an empathic alliance such interventions lose their success.
It’s Purpose in Maintenance and Prevention
Studies have shown the importance of both technique and the relationship between client and therapist with both in regards to therapeutic change. These components enhance the effectiveness of therapy when considered as one. Research has presented results where interventions have illustrated better success rates when accompanied with a compassionate relationship, even those techniques that require specific steps and actions (Horvath, 2000). He goes on to state that such relationships also prevent clients from terminating therapeutic services early by way of fear or pressure. For example, he presents a study where exposure techniques employed by an empathic therapists proved to be more efficient compared to therapists who were less considerate and exhibited more of a robotic disposition.
Up to this point the therapeutic relationship has been discussed in terms of treatment effectiveness, here its role in the maintenance of therapy goals is covered. Relapse is an act or instance of reverting back to an original state that is sometimes common in psychotherapy, especially with addictive issues(Irvin et al., 1999). Those that experience set-backs in treatment often see their condition worsen before eventually subsiding with continued therapeutic services. Most individuals who make an attempt to change health-related behaviors such as depression, alcohol use, eating habits, etc will experience these lapses during and/or after treatment has been completed (Irvin et al., 1999). These occurrences typically are discussed and prepared for in psychotherapy in the case they do take place.
Psychotherapy and counseling research has examined the therapeutic relationship dimension in treatment outcome repeatedly with the majority of studies indicating a positive relationship between therapist perception and treatment effectiveness (Ritter et al., 2002). Therefore, positive treatment outcomes require therapists to convey an understanding of their client, indicating empathy and genuineness. Ritter et al. (2002) state these characteristics contribute more variance to the overall treatment and interventions employed than the client’s characteristics and therapeutic orientation. Their study found clients who perceived their relationship with their therapist to be empathic and honest to possess increased self-efficacy and coping skills attainment. For example, clients that rated their therapist as genuine and caring were more likely to retain skills learned and show increased self-worth. Therefore, the nature of the therapeutic relationship is not only directly related to treatment effectiveness, but to the client’s ability to retain their healthier mindset post-treatment. The more positive the therapy experience is for the client the better they acquire coping and prevention skills to combat relapse (Ritter et al., 2002).
Gender’s Effect on the Therapeutic Relationship and Treatment Duration
Obstacles Due to Gender in Relationship Development
It is apparent gender is an important v