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Objective: There are reasons to suggest that the therapist effect lies at the intersection between psychotherapists' professional and personal functioning. The current study investigated if and how the interplay between therapists' (n = 70) professional self-reports (e.g., of their difficulties in practice in the form of 'professional self-doubt' and coping strategies when faced with difficulties) and presumably more global, personal self-concepts, not restricted to the professional treatment setting (i.e., the level of self-affiliation measured by the Structural Analysis of Social Behaviour (SASB) Intrex, Benjamin, ), relate to patient (n = 255) outcome in public outpatient care. Method: Multilevel growth curve analyses were performed on patient interpersonal and symptomatic distress rated at pre-, post- and three times during follow-up to examine whether change in patient outcome was influenced by the interaction between their therapists' level of 'professional self-doubt' and self-affiliation as well as between their therapists' use of coping when faced with difficulties, and the interaction between type of coping strategies and self-affiliation. Results: A significant interaction between therapist 'professional self-doubt' (PSD) and self-affiliation on change in interpersonal distress was observed. Therapists who reported higher PSD seemed to evoke more change if they also had a self-affiliative introject. Therapists' use of coping strategies also affected therapeutic outcome, but therapists' self-affiliation was not a moderator in the interplay between therapist coping and patient outcome. Conclusion: A tentative take-home message from this study could be: 'Love yourself as a person, doubt yourself as a therapist'. Copyright © 2015 John Wiley & Sons, Ltd. Key practitioner messages: The findings of this study suggest that the nature of therapists' self-concepts as a person and as a therapist influences their patients' change in psychotherapy. These self-concept states are presumably communicated through the therapists' in-session behaviour. The study noted that a combination of self-doubt as a therapist with a high degree of self-affiliation as a person is particularly fruitful, while the combination of little professional self-doubt and much positive self-affiliation is not. This finding, reflected in the study title, 'Love yourself as a person, doubt yourself as a therapist', indicates that exaggerated self-confidence does not create a healthy therapeutic attitude. Therapist way of coping with difficulties in practice seems to influence patient outcome. Constructive coping characterized by dealing actively with a clinical problem, in terms of exercising reflexive control, seeking consultation and problem-solving together with the patient seems to help patients while coping by avoiding the problem, withdrawing from therapeutic engagement or acting out one's frustrations in the therapeutic relationship is associated with less patient change.
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Love Yourself as a Person, Doubt Yourself as a
Therapist?
Helene A. Nissen-Lie,
1
*Michael Helge Rønnestad,
1
Per A. Høglend,
2
Odd E. Havik,
3
Ole Andrè Solbakken,
1
Tore C. Stiles
4
and Jon T. Monsen
1
1
Department of Psychology, University of Oslo, Oslo, Norway
2
Institute of Clinical Medicine, University of Oslo, Oslo, Norway
3
Department of Clinical Psychology, University of Bergen, Bergen, Norway
4
Department of Psychology, NTNU, Trondheim, Norway
Objective: There are reasons to suggest that the therapist effect lies at the intersection between psycho-
therapistsprofessional and personal functioning. The current study investigated if and how the inter-
play between therapists(n= 70) professional self-reports (e.g., of their difculties in practice in the
form of professional self-doubtand coping strategies when faced with difculties) and presumably
more global, personal self-concepts, not restricted to the professional treatment setting (i.e., the level
of self-afliation measured by the Structural Analysis of Social Behaviour (SASB) Intrex, Benjamin,
1996), relate to patient (n= 255) outcome in public outpatient care.
Method: Multilevel growth curve analyses were performed on patient interpersonal and symptomatic
distress rated at pre-, post- and three times during follow-up to examine whether change in patient out-
come was inuenced by the interaction between their therapistslevel of professional self-doubtand
self-afliation as well as between their therapistsuse of coping when faced with difculties, and the
interaction between type of coping strategies and self-afliation.
Results: A signicant interaction between therapist professional self-doubt(PSD) and self-afliation
on change in interpersonal distress was observed. Therapists who reported higher PSD seemed to
evoke more change if they also had a self-afliative introject. Therapistsuse of coping strategies also
affected therapeutic outcome, but therapistsself-afliation was not a moderator in the interplay
between therapist coping and patient outcome.
Conclusion: A tentative take-home message from this study could be: Love yourself as a person, doubt
yourself as a therapist. Copyright © 2015 John Wiley & Sons, Ltd.
Key Practitioner Messages:
The ndings of this study suggest that the nature of therapistsself-concepts as a person and as a ther-
apist inuences their patientschange in psychotherapy.
These self-concept states are presumably communicated through the therapistsin-session behaviour.
The study noted that a combination of self-doubt as a therapist with a high degree of self-afliation as a
person is particularly fruitful, while the combination of little professional self-doubt and much positive
self-afliation is not.
This nding, reected in the study title, Love yourself as a person, doubt yourself as a therapist, indi-
cates that exaggerated self-condence does not create a healthy therapeutic attitude.
Therapist way of coping with difculties in practice seems to inuence patient outcome.
Constructive coping characterized by dealing actively with a clinical problem, in terms of exercising re-
exive control, seeking consultation and problem-solving together with the patient seems to help
patients while coping by avoiding the problem, withdrawing from therapeutic engagement or acting
out ones frustrations in the therapeutic relationship is associated with less patient change.
Keywords: Therapist effects, Therapist Personal and Professional Selves, Patient Outcome, Multilevel
Growth Curve Modelling
*Correspondence to: Nissen-Lie Helene, Department of Psychology, University of Oslo, P.O. Box 1094, Blindern, 0317 Oslo, Norway. E-mail:
h.a.nissen-lie@psykologi.uio.no
Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 24,4860 (2017)
Published online 9 October 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1977
Copyright © 2015 John Wiley & Sons, Ltd.
The Therapist as a Professional and as a Person
It may be difcult to compare the work of psychotherapy
with other professions because of its specic requirement
that, to be of help to clients, the therapists must succeed
in integrating their professional capacities and expertise with
their personal attributes in a way that almost blurs the dis-
tinction between them. That is perhaps why neitheron
the one handtherapist professional qualications, such
as years of professional experience, amount or type of
training, adherence to treatment protocols or competence
in delivering interventions, noron the other handglobal
personality traits or general emotional well-being, have
been found to consistently predict psychotherapy process
and outcome (Barber, 2009; Beutler et al., 2004, Lambert &
Barley, 2002; Tracey, Wampold, Lichtenberg, & Goodyear,
2014, Tschuschke et al., 2014; Webb, DeRubeis, & Barber,
2010; Wolff & Hayes, 2009).
Based on a review of the literature on therapist character-
istics, our suggestion is that professional qualications
(such as competence related to diagnostic assessment and
technical skills) must merge in an optimal way with
the personal and uniquely subjective aspects of therapists
(i.e., their ways of being with others, attachment style,
personality and non-verbal expressiveness) to create
effective practice (Strupp & Anderson, 1997; Heinonen,
Lindfors, Laaksonen, & Knekt, 2012). This claim corre-
sponds logically to the current notion that it is not specic
therapeutic interventions or common factors that account
for the effect of psychotherapy but rather the interaction
or even the synergy between the two (Nissen-Lie, 2013;
Norcross & Lambert, 2011; Wampold & Imel, 2015). On the
basis of our own previous research and other researchers
studies on what characterizes effective and ineffective thera-
pists, in the current study, we aim to explore the potential
interplay between some aspects of psychotherapistsprofes-
sional and personal functioning.
Therapist Characteristics Inuencing Therapy
Outcomes
The individual therapist seems to matter as much to the ef-
fect of treatment as any of the other notable factors in psy-
chotherapy, such as the therapeutic alliance (Wampold &
Imel, 2015). That is, both the individual therapist and the
quality of the alliance explain around 57% of outcome in
studies portioning outcome variation (e.g., Baldwin &
Imel, 2013; Benish & Imel, 2008, Laska, Gurman, &
Wampold, 2014).
Hence, therapists seem to differ in effectiveness; how-
ever, what it takes to be a good therapist, who should
enter training, how we should train therapists to work
optimally and whether therapists get better at what they
do over time are questions that await rm empirical
answers. Recent studies show that therapistspersonal
and interpersonal qualities seem to be particularly rele-
vant to psychotherapy outcome, for example, their facili-
tative interpersonal skills (Anderson et al., 2009); their
capacity for afrmation, responsiveness, genuineness and
empathy with different types of clients (Bohart, Elliott,
Greenberg, & Watson, 2002)but also their being convinc-
ing and persuasive (Oddli & Rønnestad, 2012; Wampold,
2014); their ability to resist counter-aggression when
confronted with devaluation and rejections by patients
(Lambert & Barley, 2002; Safran, Muran & Eubanks-Carter,
2011; von der Lippe, Monsen, Rønnestad, & Eilertsen,
2008); and their ability to manage countertransference
reactions (Hayes, Gelso, & Hummel, 2011). As already
mentioned, thus far, these factors seem more important
than more professional factors, such as practice experience,
training, as well as adherence and competence, in
distinguishing between therapists (Beutler et al., 2004;
Trac e y et al., 2014; Wampold & Imel, 2015; Webb,
DeRubeis, & Barber, 2010). Even though we have empiri-
cally based indications that many psychotherapists over
time integrate their personal characteristics into their
professional work (e.g., Rønnestad & Skovholt, 2013), we
do not know if or how such integration may impact
processes and outcomes of psychotherapy. We know little
about how the relationship between psychotherapists
personal and professional functioning may impact pro-
fessional role performance. On this background, we seek
to explore how selected aspects of professional and per-
sonal characteristics interact in contributing to more or less
change in patients.
Therapist Self-Perceptions
In order to examine the interaction between therapists
self-concepts as a person and as a therapist, we relied on
measures of psychotherapist functioning as observed from
the psychotherapists themselves. The value of self-report
in psychotherapy has been questioned (see Dunning,
2005; Orlinsky, Rønnestad, & Willutzki, 2004). Despite this,
associations between therapist self-appraisals and patient
outcome have been reported in a number of recent studies
applying therapist measures developed by the Society for
Psychotherapy Research Collaborative Research Network
(CRN) (Orlinsky & Rønnestad, 2005), collected via the
large-scale survey Development of Psychotherapists Common
Core Questionnaire (DPCCQ). This includes therapist self-
assessed work involvement styles; difculties in practice;
coping strategies; interpersonal functioning; in-session
feelings; and quality of personal lives (Hartmann et al.,
2014; Heinonen et al., 2012; 2013; Nissen-Lie, Monsen, &
Rønnestad, 2010; Nissen-Lie, Havik, Høglend, Monsen, &
Rønnestad, 2013; Nissen-Lie et al., 2013; Zeek et al., 2012).
49Relationship of Therapist Professional and Personal Functioning to Therapeutic Outcome
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
Of particular interest to this study, two factors measured
by the DPCCQ reecting therapistsdifculties in practice,
Professional Self-Doubt(PSD) and Negative Personal Re-
action(NPR), were shown to be the most powerful, in
terms of explained variance, therapist predictors of process
and outcome in the same sample as was used in the current
study (Nissen-Lie et al., 2010; Nissen-Lie et al., 2013). How-
ever, these factors were related to process and outcome in
opposing ways; while NPR had a negative effect on
alliance and was associated with higher levels of interper-
sonal distress during treatment, PSD had a benecial effect
with regard to early patient-rated working alliance and
patient change in interpersonal distress. Due to the initially
unexpected favourable effect of PSD, the factor was
interpreted as indicating a therapistshealthy self-criticism
and ability to be open, sensitive, reexive and taking
responsibility for relationship struggles in therapy, and
not as a measure of justied concern about ones actual
competence.
Nonetheless, why self-doubt is a constructive and bene-
cial aspect of a therapistsrepertoire in treating clients is
still an open question. With reference to this nding,
Macdonald and Mellor-Clark (2014) argue that clinicians
work more effectively when they are more conscious of
challenges and uncertainties of their work and less
blindedby their own competence: Therapists who are
more aware of their natural limitations, and more realistic
about the likelihood of poorer client outcomes, are more
alert to indications that their clients are off-track, en-
abling them more frequently to resolve barriers to thera-
peutic progress. Tracey et al. (2014) reason that PSD may
encompass a critical evaluation of ones work from a
disconrming stance(p. 225). The constructive conse-
quence of a self-critical stance is also consistent with the
thinking of Baltes and Smith (1990) who suggested an atti-
tude of uncertaintyas one criterion of wisdom, and with
Rønnestad and Skovholt (1991), who suggested aware-
ness of the complexity of therapeutic work(Rønnestad &
Skovholt, 2013) as a characteristic of optimal professional
development.
Interpersonal Theory and the Concept of Self-
Afliation
In planning this study, we asked what is needed in a ther-
apist for professional self-doubt to be of benet to the
client and were reminded of the seminal Vanderbilt stud-
ies, which reported an empirical link between therapists
introjects and the interpersonal process and outcome in
short-term psychodynamic psychotherapy (e.g., Henry
et al., 1990). Referring to conscious and unconscious ways
of treating oneself, the concept of the introject lies at the core
of interpersonal theory (e.g., Sullivan, 1953; Leary, 1957). In
this tradition, which is founded on both the object relational
school within psychodynamic theory (e.g., Mahler, Pine, &
Bergman, 1975) and the interpersonal circumplex model
of personality (e.g. Leary, 1957), one assumes that a person
treats oneself at the internal level in accordance with how
he or she was treated by primary caregivers and treat
others in accordance with this inner mental representation.
If a person is treated predominantly with love, care and tol-
erance, an internalized way of treating oneself with care
and nurture would resultwhichinturncreatesatolerant
and warm approach to other people. In contrast, interper-
sonally critical and cold behaviour from parents or other
caregivers would result in a harsh manner of treating
oneself. Based on these models of personality, Benjamin
(1996) created the Structural Analysis of Social Behaviour
(SASB) methodology to describe and measure these
structures and interpersonal patterns. The SASB instrument
operationalizes intrapersonal and interpersonal dynamics
as revolving around the two main dimensions of Afliation
and Dominance, creating eight distinct combinations
(clusters), and as reected in three surfaces: (a) the transi-
tive surface (interpersonal actions towards others); (b) the
intransitive surface (interpersonal reactions to others
actions against oneself); and (3) the introject (introjected
actions directed towards oneself). This latter part of the
instrument was used to assess therapistsways of treating
themselves as persons in the current study (see Figure 1
and Measures). Empirical evidence of a robust association
between introject states and psychopathology is being
built-up (see Bjerke, Solbakken, Friis & Monsen, in press;
Halvorsen & Monsen, 2007). We are unaware of studies
reporting a link between therapistsintrojects and patient
outcome, except for the Vanderbilt studies (e.g., Henry
et al., 1990), in which the researchers hypothesized that
the therapistsintroject status would affect their interper-
sonal behaviour in a way that would provide corrections
Figure 1. The introject surface of the simplied Structural Anal-
ysis of Social Behavior cluster model (Benjamin, 1996)
50 H. Nissen-Lie et al.
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
to, or serve to reinforce, the patientsmaladaptive introject
states. The results demonstrated that therapists with more
hostile and disafliative introjects engaged in a higher
number of subtly hostile interpersonal behaviour towards
patients, which in turn were correlated with more self-
blaming behaviour and poorer outcome in patients.
Based on the above mentioned research, we anticipated
that the therapistslevel of personal self-afliation may
enhance the effect that professional self-doubt has on
change in interpersonal distress. Self-doubt in the context
of a tolerant and self-afliative introject is different than
in the context of a more disafliative introject, we
hypothesized. This formed the basis of our rst research
question.
Moreover, we were also interested in examining how
therapistschoice of coping strategies when faced with
difculties in psychotherapy practice would relate to
patient outcomes. Therapists likely use an array of differ-
ent ways of dealing with challenges in their therapeutic
work, which are more or less conscious and intentional
(Orlinsky & Rønnestad, 2005), and potentially affect the
quality of their work. The DPCCQ survey package, which
was used to tap the therapistsprofessional characteristics
in this study, includes a questionnaire aimed at assessing
therapist coping strategies. The item scales of this
questionnaire were developed through a qualitative pro-
cess of eliciting cliniciansnarratives of coping strategies
when experiencing difculties in practice (Davis, Elliott,
et al., 1987a). These accounts formed the basis for
constructing a questionnaire that was included in the
DPCCQ (see Measures). The coping strategies assessed
by the DPCCQ spans different categories such as exercis-
ing reexive control,seeking consultation,reframing the
helping contract and less commonly used strategies such
as avoiding the problem or acting out the frustration with
the client (Orlinsky & Rønnestad, 2005). The DPCCQ
scales have been factor analysed into one factor contain-
ing positive aspects of coping (i.e., constructive coping)
and one with more negative, maybe even destructive, el-
ements (non-constructive coping or avoiding therapeutic
engagement) (Orlinsky & Rønnestad, 2005); the former
making part of a healing involvement stylewhile the
latter is a component of stressful involvement(Orlinsky
& Rønnestad, 2005). The predictive validity of these
factors have previously been tested in the Helsinki Psycho-
therapy Project (Knekt et al., 2011); a study of 326 outpa-
tients suffering from mood or anxiety disorders. In
investigating the relative importance of both professional
and personal therapist characteristics measured by the
DPCCQ, it was demonstrated that the two factors,
constructive and non-constructive coping, are related to
alliance and outcome in short-term and long-term treat-
ments (Heinonen et al., 2012; 2013). In the current study,
we examined the effect of constructive and non-
constructive coping as predictors of patient outcome (see
research question 2), as well as examining if an effect of
coping may be moderated by the therapistsself-afliation
(research question 3), with the same logic as was applied
when formulating research question 1.
Research Questions and Hypotheses
The following research questions were investigated:
1. Does therapistsself-afliative introject status moder-
ate the relationship between PSD and patient change
in interpersonal distress? We hypothesized that PSD
would have a more benecial effect on outcome when
therapists also reported higher levels of self-afliation.
2. Does therapistsuse of coping strategies when faced
with difculties in practice affect patient outcome?
We hypothesized that constructive coping would af-
fect outcome in a positive fashion, while non-
constructive coping would have a negative impact.
3. Does therapist self-afliation moderate a relationship
between coping strategies and patient outcome?
METHOD
Participants
Patients
The data used in the study came from the Norwegian
Multisite Study of the Process and Outcome of Psycho-
therapy (NMSPOP) (Havik et al., 1995). As previously
described (Nissen-Lie et al., 2010; 2013), the NMSPOP is
a naturalistic outpatient psychotherapy project involving
370 patients who were treated at 16 public outpatient
clinics within the Norwegian public mental health care
system, organized at eight different research sites. The
treatments were inuenced mainly by psychodynamic
treatment models, although they were still rather eclectic
and could be classied as treatment-as-usual, that is, no
protocols or special supervision were used (see the section
on Therapists below), except that three of the eight sites
provided Affect Consciousness treatment (Monsen &
Monsen, 1999). The patients were recruited from 1996 to
2000, and by the end of 2005, all treatments in this project
had been terminated. The mean number of sessions in
the NMSPOP was fairly large (52), which in part may be
due to the relatively high level of clinical disturbance in
the patient sample (see below). The patients were referred
to public outpatient clinics for assessment and treatment of
a wide range of clinical symptoms and disorders. The
inclusion policy was liberal, so as to ensure a typical outpa-
tient sample. Only patients with serious substance abuse
problems, acute crises requiring hospitalization and
psychoses were excluded from the study. Of the total
51Relationship of Therapist Professional and Personal Functioning to Therapeutic Outcome
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
sample, 48% comprised patients suffering from at least one
personality disorder. The analyses of patient outcome pre-
sented below were conducted on a subsample of patients
(n= 255) who had provided a minimum of three mea sure-
ments of the two outcome measures [Inventory of Inter-
personal Problems (IIP) and Global Severity Index (GSI)],
so as to allow for growth curve modelling (Hox, 2010). This
subsample included 169 (74.4%) women and 58 (25.6%)
men, whose ages rang ed from 18 to 65 years, with a mean
of 35.7 years [standard deviation (SD) = 9.52]. The most fre-
quent Axis 1 DSM-IV diagnoses in this sample were anxi-
ety disorders (67%; e.g., social phobia or generalized
anxiety) and affective disorders (55.9%; e.g., major depres-
sion or dysthymia). Half (50.2%) of the patients met the
criteria for at least one personality disorder. The level of
psychosocial functioning at baseline, as measured by the
Global Assessment of Functioning scale (Endicott, Spitzer,
Fleiss, & Cohen, 1976), ranged from 20 to 85, with a mean
of 57.6 (SD = 8.9).
Therapists
The therapists were assessed using the comprehensive
self-report survey DPCCQ (Orlinsky et al., 1999; Orlinsky
& Rønnestad, 2005; see below). The therapist sample
consisted of 70 psychotherapists [(46 psychologists, 14 psy-
chiatrists, 8 physiotherapists specializing in Psychody-
namic Body Treatment (see Monsen & Monsen, 2000) and
2 psychiatric nurses]. Their level of experience in practicing
psychotherapy ranged from 0 to 28 years, with the mean be-
ing 10.0 years (SD = 6.57). Their caseload included in the
study ranged from 1 to 11 patients, with the average being
almost ve patients each. The degree to which therapists
were inuenced by various theoretical orientations in their
therapeutic work was measured by a ve-point Likert scale,
ranging from 1 (not at all)to5(very much), exibly allowing
for ratings of multiple orientations. Based on the therapists
responses to this questionnaire, the majority in the sample
(78.3%) reported a psychoanalytic/psychodynamic salient
orientation, which is dened as a rating of four or more on
the ve-point scale included in the DPCCQ. A substantial
portion of therapists in the sample also reported having a
salient orientation in the humanistic (29.4%) and/or cogni-
tive (28.7%) treatment models.
Measures
Outcome Variables
Interpersonal Problems. The rst outcome variable used
was global interpersonal problems assessed using the Nor-
wegian translation of the Inventory of Interpersonal Prob-
lems with 64 items (IIP-64) (Horowitz, Alden, Wiggins, &
Pincus, 2000). The IIP-64 contains two types of items: 39
items follow the phrase It is hard for me to…’ and the
other 25 items describe Things that you do too much.
Each item was rated on a ve-point scale ranging from 0
(not at all)to4(extremely). A total interpersonal distress
score (IIP global) was calculated from the mean of the IIP-
64 at pre-treatment, post-treatment and three times during
follow-up (at 6, 12 and 24 months after treatment termina-
tion). This global score is interpreted as the best structural
index of an individuals interpersonal adjustment
(Gurtman & Balakrishnan, 1998, p. 350). The testretest reli-
ability, internal consistency and construct validity of the IIP-
64 have been demonstrated to be excellent (Horowitz et al.,
2000). This also includes the Norwegian translation of the in-
strument (Monsen et al., 2006). The average IIP-64 global
score in the sample at baseline was 1.49 (SD =0.54, range
0.162.81).
Symptom Distress. The second outcome variable was
symptom distress as measured by the revised Symptom
Checklist-90 (Derogatis, 1983), which is a self-report ques-
tionnaire composed of 90 items tapping nine different
symptom dimensions. The 90 items are rated from 0 (not
at all)to4(very much). The responses to the items were av-
eraged in the standard GSI gathered at pre-treatment,
post-treatment and three times during follow-up. The
GSI is regarded as well suited to represent patientsgen-
eral psychopathology and psychological distress, and its
sensitivity to change through psychotherapy has been
demonstrated (e.g., Ogles, Lambert, & Masters, 1996).
Clinical cut-off ranges for the GSI have been established
in a number of studies of normative samples. Scores over
0.97 (with a condence interval of 0.761.19) indicate se-
vere psychological distress (Lambert, Burlingame, &
Hansen, 1996). In the patient sample, the GSI at pre-
treatment was 1.27 (SD = 0.62, range = 0.163.34), and 163
(63 %) of the patients in the present investigation started
out as severely distressed (GSI 0.97).
Therapist Measures
Survey instrument; Development of Psychotherapists Common
Core Questionnaire. The therapist variables were measured
using the comprehensive self-reported DPCCQ question-
naire (Orlinsky et al., 1999), which contains 370 questions
from several questionnaires divided in subsections (de-
scribing professional training and experience, professional
development, current experiences of therapy and personal
characteristics). Responses to this battery of question-
naires have presently been gathered from more than
11000 psychotherapists. Using data available at the time
(n= 4923), Orli nsky and Rønnestad (2005) conducted prin-
cipal component analyses on several of the DPCCQ sub-
scales in order to reduce the measures to a manageable
set and to uncover underlying factor structures which
has generated the model of therapists work involvement
based on the scales describing therapistscurrent experi-
ences of therapeutic work (Orlinsky & Rønnestad, 2005).
52 H. Nissen-Lie et al.
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
In the current study, the factor scales of one type of dif-
culties in practice (PSD), and coping strategies, which are
subdimensions of these work involvement styles, were
used as independent variables.
Professional Self-Doubt. Professional self-doubt is a factor
consisting of nine items included in the DPCCQ scale
measuring difculties in practice by means of statements
describing typical challenges in psychotherapy practice.
These difculty types were originally identied through
a qualitative research process in which the researchers
constructed a consensual set of experimental categories
that could reliably be applied to describe accounts of dif-
culties they experienced as clinicians (Davis et al., 1987a).
These categories were made into a scale of 21 statements
and included in the DPCCQ following the question:
Presently,how often do you feelResponses are made on a
six-point Likert-type scale ranging from 0 (never)to5(very
often). Principal component analyses on the responses
provided by 4923 psychotherapists to this questionnaire
yielded three reliable factors, which were termed PSD,
NPRand frustrating treatment case(FTC) (Orlinsky &
Rønnestad, 2005). The rst two were reproduced through
factor analysis in the current sample of psychotherapists
(Nissen-Lie et al., 2010). Only PSD was investigated in the
present study because of its unexpected association with
higher patient alliance evaluations and therapeutic change
that we wanted to explore in more depth in the current
study. PSD reects self-questioning about ones profes-
sional efcacy in treating clients and includes the follow-
ing nine items: Lacking in condence that you might have a
benecial effect on a patient;Unsure how best to deal effectively
with a patient;Distressed by powerlessness to affect a patients
tragic life situation;Disturbed that circumstances in your pri-
vate life will interfere with your work;In danger of losing control
of the therapeutic situation with a patient;Afraid that you are
doing more harm than good in treating a client;Demoralised
by your inability to nd ways to help a patient;Unable to gener-
ate sufcient momentum;Unable to comprehend the essence of a
patients problems. The factor obtained a high internal
consistency score in the general sample of therapists
(Orlinsky & Rønnestad, 2005), as well as in current sample
(Cronbach alpha = 0.90).
Coping Strategies. Therapistscoping strategies were mea-
sured in the DPCCQ with a questionnaire of 26 items,
based on qualitative accounts that emerged through a
similar research strategy as the difculty accounts (also
developed by Davis et al., 1987b), following the question:
When in difculties, how often do you.. Responses are
made on a six-point Likert-type scale ranging from 0
(never)to5(very often). The questionnaire items were
subjected to factor analysis in a larger Norwegian repre-
sentative sample (n= 1678) yielding two factors which
were termed, as in the larger CRN study: constructive
coping and non-constructive coping/avoiding therapeu-
tic engagement (Orlinsky & Rønnestad, 2005). The factor
structure found in this Norwegian, larger sample was
similar to the structure of the international CRN data
with the exception of three additional items, which
loaded on the factor non-constructive copingonly in
the Norwegian data set (see below). The coping factors
obtained satisfactory reliability scores in the current
sample (n= 70). See below for items in each of the coping
factors.
Constructive coping (alpha = 0.72).
1. Try to see the problem from a different perspective
2. Share your experience of difculty
3. Discuss problem with a colleague
4. Consult relevant articles
5. Involve another professional
6. Review privately with yourself how the problem arose
7. Just give yourself permission to experience difcult or
disturbing feelings
8. See whether you and your patient can together deal with
the difculty
9. Consult about the case with a more experienced therapist
10. Sign up for a conference
Non-constructive coping (alpha = 0.60).
1. Simply hope things will improve eventually
2. Criticize a client for causing you trouble
3. Seriously consider terminating therapy
4. Avoid dealing with the problem
5. Show your frustration
6. Postpone the work of therapy
1
7. Step out of the therapist role in order to take some ur-
gent action on a patients behalf
8. Make changes to the therapeutic contract with a
patient
The Coping Strategies Scale has demonstrated predic-
tive validity in previous research; constructive coping pre-
dicted alliance and outcome in a positive manner and
non-constructive coping (avoiding therapeutic engage-
ment) was negatively associated with alliance and out-
come, as would be expected (Heinonen et al., 2012; 2013).
Self-Afliation. To use the psychotherapistslevel of self-
afliation as a moderator in the study (see below), the
therapist samples responses to the Norwegian version
(Monsen et al., 2007) of the SASB Introject Surface Long
Form A (Benjamin, 1996) were used. This instrument
1
Items in bold were part of this dimension only in the Norwegian
sample (n= 1678).
53Relationship of Therapist Professional and Personal Functioning to Therapeutic Outcome
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
contains 36 items describing how one treats oneself as a
person. In the original SASB questionnaire, respondents
are asked to rate themselves at their bestand their
worst. In this study, however, the therapists were
instructed to rate themselves as they usually are. Chang-
ing this instruction was perform to increase the probabil-
ity of measuring more stable aspects of self-relatedness
(Bjerke et al., in press; Svartberg, Seltzer, & Stiles, 1996;
Halvorsen & Monsen, 2007). The items of the SASB make
eight clusters (cluster 1, 3, 5 and 7 comprising ve items
each; while cluster 2, 4, 6, and 8 comprise four items).
These clusters form a circumplex within a two-
dimensional space dened by the dimensions Afliation
(horizontal axis) and Dominance(vertical axis) (e.g., Leary,
1957; Figure 1). Item statements like: I think up ways to
hurt and destroy myself. I am my own worst enemy
(cluster 7, self-attack) and I tenderly cherish myself
(cluster 3, self-love) are rated on a scale from 0 (never, not
at all) to 10 (always, perfectly). The SASB Introject Surface
has obtained acceptable reliability scores, and correspon-
dence with external criteria supports the validity of the
scale in clinical and non-clinical samples (Monsen et al.,
2007; Halvorsen & Monsen, 2007).
In the present study, the weighted cluster scores along
the horizontal, self-afliation, dimension of SASB were
used (e.g., Bjerke et al., in press) according to a calculation
suggested by Pincus et al. (1998):
Self affiliation ¼0x cluster1þ4:5x cluster2
þ7:8x cluster3þ4:5x cluster4
þ0x cluster5minusðÞ4:5x cluster6
7:8x cluster74:5x cluster8:
This operational denition of self-afliation weights
cluster 3 (self-love) and 7 (self-attack) the most (the latter
in a negative way), before cluster 2 (self-afrm), cluster 4
(self-protect), cluster 6 (self-blame) and cluster 8 (self-ne-
glect); the latter two in a negative way.
See Table 1 below for descriptive statistics and intercor-
relations of the therapist variables used in this study.
Procedure
The study investigated two different outcome measures as
dependent variables (GSI and IIP global). These data were
collected before the start of treatment, at treatment termi-
nation and three times during follow-up: at 6, 12 and
24 months after treatment. The therapists completed the
DPCCQ self-report survey a maximum of six times during
the project period with one year interval. Like in the for-
mer studies on working alliance and outcome (Nissen-Lie
et al., 2010; 2013), the therapist scores of the second
DPCCQ administration were used as the basis for analyses
because some of the variables (e.g., coping strategies) were
not included in the rst version. The SASB scores were col-
lected when the therapists were enrolled in the study.
Note that there was no systematic time relationship be-
tween the assessments of the three outcome measures,
DPCCQ Questionnaires and the SASB, owing to the con-
tinuing inclusion of patients and therapists into the project,
so that the individual treatment processes had different
starting points, which were not related to the therapist
assessments.
Data Analyses
Multilevel Growth Curve Modelling
Multilevel growth curve analyses were performed on
255 patients treated by the 70 psychotherapists. Because
repeated measures (Level 1) were nested within patients
(Level 2), who were nested within therapists (Level 3),
we used a three-level, hierarchically nested random effects
growth model to analyse the effect of therapist predictors
on change in IIP and GSI. A primary reason to use these
methods is to account for non-independence in the data.
Failure to account for data dependence could result in an
underestimation of the standard errors (in this case of the
therapist-level predictors), which could lead to in an
inated Type I error rate (Raudenbush & Bryk, 2002; Snijders
& Bosker, 1993). Multilevel modelling (MLM) is also robust in
allowing for missing observations or unequally distributed
measurement waves per unit, which are typical problems in
longitudinal, naturalistic psychotherapy research (Hox,
2002; Tasca, Illing, Joyce, & Ogrodniczuk, 2009). A therapists
were treated as a random factor. That is, randomly distrib-
uted intercepts and slopes were tted for each therapist in
order to account for nesting.The multilevel growth curve
analyses were performed on each of the two outcome mea-
sures; IIP total and GSI consecutively, using a timevariable
and the therapist predictors examined in three different
models. The timevariable reected the measurement waves
of 15 for the outcome measures (pre-treatment, post-
treatment and three follow up measurements), which were
log transformed (into the variable called LOGTIME)because
Table 1. Descriptives and intercorrelations of the therapist
predictors (n=70)
Therapist
factors
MSD Min Max 1 2 3 4
1 PSD 1.24 0.70 0.11 3.78
2 CC 3.03 0.61 1.50 4.40 0.19*
3 NC 1.13 0.43 0.25 2.00 0.19* 0.13
4 SASB_AFF 113.8 43.8 0.00 194 0.36** .28** 0.09
PSD = professional self-doubt. CC = constructive coping. NC = non-con-
structive coping. SASB_AFF = self-afliation from Structural Analysis of
Social Behaviour Intrex. SD, standard deviation.
**Correlation is signicant at the 0.01 level (two-tailed).
*Correlation is signicant at the 0.05 level (two-tailed).
54 H. Nissen-Lie et al.
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
the t indices (e.g., 2LL; AIC) indicated a better tfor
loglinear growth. This is a common procedure in psycho-
therapy research because change typically is steeper at the
beginning (from pre-treatment to post-treatment) and then
attens during the follow-up period (Tasca et al., 2009).
All models were estimated using maximum likelihood
(ML) estimation procedure as recommended by, e.g., Hox
(2010) when one has relatively large amounts of groups
(in this case 70 therapists = groups) and the main interest
is in xed effects predictor analyses. Assumptions under-
lying MLM growth curve analyses for change, such as nor-
mally distributed residuals and homogeneity of variance,
were assessed (Singer & Willett, 2003). In order to reduce
multicollinarity and to aid the interpretation of the nd-
ings, particularly concerning interaction effects, the log
transformed time variable (LOGTIME) and all predictors
were centred around the mean, as recommended in the lit-
erature (e.g., Hox, 2010; Singer, 1998). The analyses were
performed using the IBM SPSS software (version 21.0;
IBM Corporation, Armonk, New York, USA). See results
of the three models for both outcome measures summa-
rized in Table 2.
Results
Multilevel Modelling Growth Curve Procedure, Inventory
of Interpersonal Problems
Model 1a: Professional Self-Doubt and Self-Afliation. Profes-
sional self-doubt had a benecial effect on change in IIP,
while self-afliation alone did not relate to change. As hy-
pothesized, there was a signicant interaction between
PSD and self-afliation (B = 0.0034, p<0.01). See Figure 2
below for an illustration of this nding with three lines
representing change in IIP (y-axis) obtained by patients
treated by therapists with high, average and low levels of
self-afliation and with different levels of PSD (x-axis.).
Negative values of IIP (y-axis) indicate more change, and
vice versa. As can be inspected, the most change was ob-
tained by patients treated by therapists who were high
on both PSD and self-afliation, while the least change
was observed in those treated by therapists who combined
low scores of PSD with high scores on self-afliation.
Model 2a: Constructive Coping and Self-Afliation. The
model including the factor constructive coping and self-
afliation showed that constructive coping had a bene-
cial effect on change in interpersonal distress (B = 0.19,
p<0.01). Self-afliation did not moderate the relationship
between coping and change in IIP.
Model 3a: Non-Constructive Coping and Self-Afliation. Nei-
ther non-constructive coping nor its interaction with self-
afliation affected patientschange in interpersonal
distress.
Multilevel Modelling Growth Curve Procedure, Global
Severity Index
Model 1b: Professional Self-Doubt and Self-Afliation. Nei-
ther PSD and self-afliation nor the interaction between
PSD and self-afliation affected patientschange in GSI,
as shown in this model.
Model 2b: Constructive Coping and Self-Afliation. Neither
constructive coping nor its interaction with self-afliation
affected patientschange in GSI, as found in this model.
Model 3b: Non-Constructive Coping and Self-Afliation. The
model including the factor non-constructive coping and
its interaction with self-afliation showed that non-
constructive coping had a deleterious effect on change in
GSI (B = 0.19, p<0.01). Self-afliation did not moderate
the relationship between coping and change in GSI.
Table 2. Results of multilevel modelling growth curve analyses:
therapist predictors of outcome
Models IIP GSI
Model 1 Estimate/(S.E) Estimate/(S.E)
Intercept 1.22***(0.03) 0.88***(0.04)
Fixed slope 0.57***(0.04) 0.71***(0.07)
PSD 0.04(0.05) 0.009(0.06)
PSD*slope 0.18**(0.06) 0.04(0.07)
SASB_AFF 0.00008(0.0008) 0.001(0.0009)
SASB_AFF*slope 0.0001(0.001) 0.0003(0.001)
PSD*Slope*SASB_AFF 0.0035**(0.001) 0.001(0.001)
Model 2
Intercept 1.24***(0.03) 0.87***(0.04)
Fixed slope 0.53***(0.04) 0.69***(0.05)
CC 0.09(0.06) 0.07(0.08)
CC*Slope 0.14*(0.07) 0.06(0.15)
SASB_AFF 0.0002(0.0008) 0.0001(0.0009)
SASB_AFF*Slope 0.0001(0.0009) 0.0002(0.001)
CC*Slope*SASB_AFF 0.001(0.001) 0.00005
Model 3
Intercept 1.23***(0.02) 0.87***(0.04)
Fixed slope 0.57***(0.04) 0.69***(0.05)
NC 0.009(0.008) 0.04(0.09)
NC*Slope 0.03 (0.09) 0.23*(0.11)
SASB_AFF 0.0002(.002) 0.0007(0.0009)
SASB_AFF*Slope 0.0003(0.0001) 0.0001(0.001)
NC*Slope*SASB_AFF 0.00001(0.001) 0.00008(0.002)
PSD = professional self-doubt. CC = constructive coping. NC = non-
constructive coping. SASB_AFF = self-afliation from Structural Analysis
of Social Behaviours Intrex. IIP = Inventory of Interpersonal Problems.
GSI = Global Severity Index.
*p0.05.
**p0.01.
***p0.001, n= 70. Estimation method: maximum likelihood; bold charac-
ters indicate signicant results. All predictors, including the slope
(LOGTIME) are centred, so in the models, the intercepts represent the
mid-score.
55Relationship of Therapist Professional and Personal Functioning to Therapeutic Outcome
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
DISCUSSION
From our own previous research, we know that therapists
level of PSD has been demonstrated to be a strong, positive
predictor of early patient-rated alliance and patient change
in naturalistic psychotherapy (Nissen-Lie et al., 2010; 2013).
In the current study, we hypothesized that this effect might
be inuenced by the psychotherapistslevel of self-
afliation (Benjamin, 1996; Pincus et al., 1998); a stable core
of tolerance and nurturance in the personal self that we
expected would increase the benet of professional self-
doubt in therapeutic effectiveness. Our ndings provided
preliminary support for this idea. Interestingly, in our anal-
yses, it was demonstrated that self-afliation did not on its
own affect change, neither with regards to patient general
interpersonal distress nor to their global symptom distress.
This substantiates the notion that more global aspects of a
therapistspersonality structurethat are not specicto
therapeutic situationsare not predictive of outcome,
probably because they are too distant from the therapeutic
situation to be relevant (Beutler et al., 2004; Wolff & Hayes,
2009). On the other hand, as we hypothesized, the interac-
tion between PSD and self-afliation predicted change sig-
nicantly. Therapists who reported more self-doubt in
their work facilitated change in patient interpersonal dis-
tress to a greater extent if they also reported to have a
self-afliative introject. Incidentally, those who combined
low scores on PSD with higher scores of self-afliation con-
tributed to the least change. The ndings imply that a
healthy self-critical stance is an ingredient of successful
professional role performance but that treating oneself as
a person with care and nurturance but lacking capacity
to critically evaluate (i.e., doubt) ones therapeutic work,
is not. The combination of personal self-afliation and
PSD seems to pave the way for an open, self-reective
stance that allows psychotherapists to respect the com-
plexity of their work, and, when needed, to correct the ther-
apeutic course in order to help clients more effectively with
their challenges (e.g., Macdonald & Mellor-Clark, 2014;
Rønnestad & Skovholt, 2013).
A contrast to professional self-doubt may be a sense of
exaggerated self-condence, which likely arises as a
defense against feelings of incompetence or lacking in
therapeutic mastery; feelings most therapists encounter
in their professional work. The concept of premature
closurehas been suggested for the unconscious or
preconscious defensive processes that therapists engage
in when not tolerating feelings of incompetence in their
work (Skovholt & Rønnestad, 1992). These processes
may nd their expression in different ways, such as in
(a) misattribution (e.g., faulty explanation for client
drop-out); (b) distortion (e.g., erroneous interpretation of
client aggression as merely a transference reaction, where
external observation suggests otherwise); and/or (c)
dysfunctional reduction of the complexities of therapeutic
work when difculties are encountered (e.g., overly sim-
plistic case formulations) (Rønnestad & Skovholt, 2013).
The current ndings suggest that combinations of profes-
sional and personal functioning in psychotherapists pro-
duce distinguishable interactional patterns that inuence
patient outcome.
Furthermore, in the current study, we found that thera-
pistsuse of coping strategies when faced with difculties
in practice also affected therapeutic outcome. As hypothe-
sized based on the nature of these constructs (Orlinsky &
Rønnestad, 2005) and from previous ndings of the
Helsinki Psychotherapy Project (Heinonen et al., 2012),
constructive coping strategies were associated with more
reduction in global interpersonal distress, while non-
constructive coping (avoiding therapeutic engagement)
negatively affected the rate of change in patient symptom
distress. Therapistsself-afliation was not a moderator
in the interplay between therapist coping strategies and
patient outcome. Hence, the effect of coping remained
uninuenced by the nature of the therapist personal self-
relatedness.
Based on these ndings, we may infer that patients are
better off meeting therapists who can allow themselves to
report higher levels of self-doubt in their clinical work
because of a more acceptant and less attacking way of
treating themselves as persons. Also, when therapists gen-
erally cope with difculties by dealing actively with the
problem, in terms of exercising reexive control, seeking
consultation and problem-solving together with the
patient (Orlinsky & Rønnestad, 2005), this seems to help
Figure 2. Change in Inventory of Interpersonal Problems (IIP)
(y-axis) for patients treated by therapists with increasing scores
(i.e., 20th, 40th, 50th, 60th and 80th percentiles) on professional
self-doubt (PSD) (x-axis) and with low (red line), medium (blue
line) or high (purple line) levels of self-afliation from Structural
Analysis of Social Behavior (SASB_AFF). Note that the negative
numbers on IIP indicate greater change
56 H. Nissen-Lie et al.
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
patients in reducing their general interpersonal distress. In
contrast, when they cope with their struggles by avoiding
the problem, withdrawing from therapeutic engagement
or acting out their frustrations in the therapeutic relation-
ship, this is associated with less change in symptomatic
distress for their patients. The fact, however, that non-
constructive coping was unrelated to patient change in in-
terpersonal distress could be due to several factors other
than it being irrelevant in creating an atmosphere in which
reduction of interpersonal problems can be achieved. First,
the internal consistency of the dimension is relatively low
considering the number of items; second, semantically,
the factor consists of items that address ways of coping
that may be fruitful at times (and detrimental at other
times), depending on the specic therapeutic situation.
This is further discussed below.
Limitations
We should note that a limitation with this study is that the
associations between therapist professional/personal
functioning and outcome were not contextualized in spe-
cic psychotherapy patienttherapist dyads. Therapists
most likely struggle with and cope differently with each
patient they see, because unique aspects of their psycho-
logical functioning are elicited and will in turn affect the
patientsfunctioning in a reciprocal transaction. This
notion corresponds to what Stiles and colleagues (1998,
2009, 2013) have termed therapist appropriate responsive-
ness, referring to therapistsability to adjust their interper-
sonal responses to the current state of the client and the
interaction (Hatcher, in press). The therapistslevel of
appropriate responsiveness is not easy to measure (see
Hatcher, in press); however, we may speculate from our
nding that PSD, in the context of a nurturing introject,
may pave the ground for it. Nonetheless, we are limited
by the fact that these concepts were measured across a
range of patients and different clinical situations. This is a
general limitation of studies that map therapist character-
istics against standard outcome measures and has
prompted McLeod (2014) to formulate the following
critique: (In such a research strategy)…‘the therapist is
conceptualized as a static entity rather than as an inten-
tional actor operating in a social context(p. 206). More-
over, the therapistscoping strategies in this study were
predened strategies (but based on an in-depth qualitative
research process) and tapped what therapists have
conscious access to. This of course does not preclude the
possibility that unconscious processes may impact what
therapists become aware of and are able to report. One
may speculate that what is more relevant in terms of the
quality of the therapy process is not the therapists
conscious coping strategies but rather their unconscious
ways of coping (or defenses) which are, per denition, dif-
cult to measure.
More generally, this is a naturalistic study with different
levels of patient pathology, therapists of varying experience
levels, little constraint as to what type of psychotherapy
was offered, and so the patients received treatments of differ-
ent types and lengths. As is often noted in comparing ran-
domizedcontrolledtrialswithnaturalisticdesigns,the
disadvantage of one is the advantage of the other. In this
case, the naturalistic nature of the data, although creating
problems when disentangling cause from effect, possesses
astrengthinthatthendings are more generalizable to
general clinical practice and hence, perhaps more feasible
for practicing therapists to be informed by and use as basis
for their self-reections.
Implications and Conclusion
The ndings suggest that therapeutic outcomes are inu-
enced by what therapists experience as difcult in practice
and the way they cope with these difculties as profes-
sionals. Moreover, how they treat themselves as persons
seems to inuence this relationship. To some degree, our
ndings support the proposal that the therapist effect lies
at the intersection between therapistsprofessional and
personal selves.
The ndings indicate that there is a link between thera-
pist self-report and patient outcome, a link that has been
hard to establish in previous studies (e.g., Anderson et al.,
2009), and for good reasons: there is a leap from therapists
accessible self-perceptions to patientsinterpersonal and
symptomatic distress experienced through treatment and
post-treatment. Nonetheless, some mechanisms suggest-
ing ways in which these factors may be linked are indi-
cated by these ndings. It is probable that therapists
serve as a role model for their clients to internalize, which
they take with them after the end of treatment, as an inter-
nal image to use in situations of distress (e.g., Halpern,
2003). When treated by therapists who can allow them-
selves to reect on their share in difculties that arise in
the therapeutic relationship, but from a nurturing stance
within them, patients may use this as a working model in
their everyday struggles and adapt their coping when in
distress, but without judging themselves. This is a notion
that teachers and supervisors should make use of in trying
to foster an atmosphere with their students and in clinical
supervision that is characterized by tolerance for not
knowing, embracing ambiguity and containing ones
shortcomings and limitations without fear of losing face
or authority, maybe by being a role model to students
themselves.
To some extent, we may suggest that the interplay
between how therapists treat themselves as a person and how
they feel about a patient during treatment affects patient
outcome. More broadly, we recommend that this notion
be incorporated in therapist training, supervision and
57Relationship of Therapist Professional and Personal Functioning to Therapeutic Outcome
Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 24,4860 (2017)
therapistseveryday self-reection. Tentatively, the take
home messagefrom this study could be formulated with
the following words: Love yourself as a person, doubt
yourself as a therapist.
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