There is substantial research showing that the person of the therapist is critical to helpful therapeutic processes and patient outcomes. One of the key therapist factors related to psychotherapy processes and outcomes is therapists’ emotional reactions to their patients in therapy. This is often referred to as countertransference, or therapists’ feelings emerging from interactions between patients’ behaviours, feelings and thoughts with therapists’ unresolved issues or conflicts. Therapists recognizing their emotions in a session may be an essential indicator of therapeutic alliance ruptures and their repairs. Therapists’ positive feelings towards patients (liking, enjoying, attachment, and pride) are associated with better patient outcomes. Therapists' negative feelings (power struggles, feeling drained, helpless, frustrated) are associated with patient resistance. Skilled therapists are responsive to patients. Responsive therapists can adjust their interventions to patients’ needs in a session, and responsiveness requires therapists to be attuned to the internal state of the patient. In this study, Abargil and colleagues were interested in the association between therapists’ feelings at the start and end of a session and patients’ perceptions of their therapist’s attunement and responsiveness. Abargil and colleagues argued that therapists’ emotional reactions to patients may enhance or reduce patients’ perception of therapists’ attunement and responsiveness. The researchers asked 40 therapist-patient dyads to complete questionnaires. Therapists rated their emotional state before and after a session using a self-report scale measuring two factors. The “Parental” factor measured therapists’ supportive and guiding stance. The “Inadequate” factor measured therapists’ sense of inadequacy or inefficacy. Self-ratings before a session may indicate how the therapist felt about the previous sessions with the patient, whereas self-ratings after a session might indicate how a therapist felt about the completed session. Patients rated the therapist and therapy at the end of the session for Felt Empathy, Perceived Helpfulness, and Sense of Accomplishment. Before sessions, the more therapists felt “parental”, the more patients perceived the therapist as empathic (b = 0.77, t = 1.98, df = 507, p = 0.048). Before sessions, the more therapists felt “inadequate”, the less patients rated the session as helpful (b = 1.83, t = .3.55, df = 528, p = 0.01), and patients had a lower sense of accomplishment (b = .1.06, t = .2.39, df = 529, p = 0.017). After sessions, the more therapists felt “parental”, the more patients rated therapists as empathic (b = 1.48, t = 3.86, df = 510, p < 0.001) and helpful (b = 1.27, t = 3.18, df = 531, p = 0.001), and patients felt a greater sense of accomplishment (b = 1.05, t = 3.09, df = 532,p = 0.002). After sessions, the more therapists felt “Inadequate”, the less patients perceived therapists as empathic (b = −1.88, t = −4.33, df = 510, p < 0.001) or helpful (b = - 2.34, t = −5.20, df = 531, p < 0.001), and patients felt a lower sense of accomplishment (b = −1.88, t = −4.33, df = 510, p < 0.001).
Practice Implications
Feeling “inadequate” before or after a session may interfere with therapists being optimally responsive to what patients need during a session. Therapists feeling “parental” (supportive, guiding) may enhance a therapeutic alliance and allow patients to benefit from a felt sense of empathy. Supervision can help therapists reflect on their different feelings and the impact of these feelings on their interpersonal stance and choice of interventions. Training to focus on their feelings may provide therapists with some clues to understanding how the session progressed and their patients’ experiences. Asking patients about their session experiences can yield helpful information to a therapist and increase patients’ sense that their therapist is responsive.
Abargil, M., Schenkolewski, A., & Tishby, O. (2025). Therapists’ emotional responses and their relation to patients’ experience of attunement and responsiveness. Psychotherapy Research, 35, 54-66. https://doi.org/10.1080/10503307.2024.2403422
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