Effects of gender on psychotherapy

Effects of Gender on Psychotherapy Lewis

A. Kirshner

INCE

FREUD AND BREUER first ventured from the security of the medical treatment model into the uncertainties of the psychotherapy relationship, psychiatrists have been aware that certain actual characteristics of the participants may have an im~rtant bearing on the evolution of that relationship. Among these traits, gender holds preeminent importance. In Gove and Tudor’s’ summary, “sex acts as a master status, channeling one into particular roles and determining the quality of one’s interaction with others,” Yet very little empirical evidence has been gathered on this subject until quite recently. Kubie’s” metaphor of therapy as a climb up a mountain, in which the routes may vary but the view from the summit is afways the same, probabty typifies the traditional wisdom with regard to individual differences, including gender, among therapists. However. the benefit of more scientific data may now afford us a somewhat clearer overview of the terrain, as we make our ascent toward understanding the verities of the psychotherapy relationship. Although no one will ever be able to disprove Kubie’s claim that the view gained at the end of therapy will be basically the same regardless of the path taken or sex of therapist chosen, clinical experience--not to say life experience in general -.-suggests that this hypothetic ideal is far from the reality. The “Rashomon effect” of Mintz et aL3 in which patient, therapist, and trained observer saw different things happening, with Fairly low agreement, more reflects the reality of treatment. As Gauron and Dickinson’ observed in diagnostic decision making in psychiatry and Koran” in medicine, clinicians’ judgments tend to varysignificantly. This being the case, gender, acting as a “master status,” certainly ought to influence clinical perceptions just as Broverman et al.” hypothesized. In fact, much recent literature, some of it polemical, takes as a given that traditional therapists -especially males--if not actually prejudicial toward female patients, are at least unequipped to understand and hetp them. The various and complex ways in which patient’s and therapist’s transference and countertransference defenses and attitudes can play around the reality of gender were discussed with great perception by Clara Thompson’ 40 years ago. A patient-s desire for a particular gender analyst, according to Thompson, represents an amalgam of defensive and adaptive patterns that may in one instance greatly facifitate and in another deiay or sabotage the treatment. Determination of suitability for a male or female therapist requires some understanding of the patient’s motivation in preferring one gender over the other, as well as the quality of major past relationships. In any event, opposition to or imposition of a particular sex of therapist is clearly antitherapeutic, and ultimately the therapeutic task of unraveling issues involved in a choice of gender must fall to

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LEWIS A. KIRSHNER

that individual therapist whom the patient chooses. Typically, the patient will then bring conflicts about relationships with members of both sexes into the treatment and will not need a later exposure to a therapist of the previously avoided gender to resolve gender-related problems. However, should both therapist and patient hold similar stereotyped notions about gender, these problems may not come to light and treatment may be unproductive under the guise of a seemingly good working relationship. Granting the irreducible complexity of each individual situation, only investigation of a series of cases can tell us whether systematic influences of gender on psychotherapy exist. These findings may then be utilized by the practitioner in broadening, if necessary, his or her awareness of possible issues to be pursued in therapy. Broverman et a1.6 in their work suggest that therapists make assumptions that might reinforce neurotic patterns disguised as normative gender behaviors. While this connection has not been empirically demonstrated, it is a fact that many women, specifically, assume that therapists will prefer a much more stereotyped role expectation for them than they would choose. In the research of Steinmann and Fox8 and Fabrikant,g male therapists actually favored a more balanced role orientation than patients believed. No doubt male patients are similarly prone to attribute distorted masculine stereotype preferences to therapists, who tend to be viewed, in Schwartz and Abramowitz’s’” phrase, as “middle-class norm-enforcers.” In these latter authors’ experimental study of psychiatric judgment and decision-making, however, as well as in a second report by Abramowitz et al.,” consistent bias against patients by race or sex was not found. They concluded that sex role biases are mediated by sociopolitical convictions. Investigations of actual therapy sessions have produced some limited evidence to show that male and female therapists may in fact behave in significantIy different ways. In the psychotherapy session project of Howard, Orlinsky, and Hill, ‘*which used postinterview questionnaire ratings, different patterns of feeling responses were reported by male and female therapists. One possible effect of these different responses was the extent to which the (female) patients claimed to experience “catharsis, mastery-insight, encouragement, or nothing.” Results of this analysisI reflected complicated interactions of patient and therapist age, gender, and marital status, suggesting that other variables may override gender as a determining factor. Utilizing process recordings of counseling sessions, Hill’l also found significant behavioral differences between the therapists of different gender-matched pairs. In Hill’s study, level of therapist experience interacted significantly with gender. Thus, therapist gender effects must be qualified by controlling for effects of several other important variables. Although woman may mistrust male therapists, they (or a significant minority) still tend to prefer an experienced male when offered a choice.‘5.‘6 Current studies may not echo Williams’s I7 1946 finding that middle class women considered insistence on a female physician “ridiculous,” but prejudice against female professionals, as Jackson’X describes, lingers, In a study of college freshman patients, this author and associates’Y found female patients of female therapists significantly less likely to describe their (assigned) therapists as competent than were patients of the other three possible gender matches. Chesler’” has used this preference for males to support her portrait of the dominant male-submissive female therapy dyad as an institutional reinforcer of traditional gender roles. The 9%~of her sample of women who “voluntarily requested” a male reported greater

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comfort with men and mistrust of women as authorities, sometimes related to feelings about their own mothers. This description seems to confirm Thompson’s’ discussion of transference feelings derived from parental relationships, which make trust and intimacy more possible with one gender therapist. One would hope that therapists’ own biases would not present a blind spot to exploring this preference. Chesler’” also notes that male therapists appear to prefer female patients, and this again has empirical validity. On the other hand, numerous studies have failed to substantiate her and Fabrikant’s!’ conclusion that therapists victimize their female patients by keeping them dependent on treatment for as long as possible. For example, in this author’s study cited above,” women reported being offered significantly more individual therapy and referred away less frequently than men. Nevertheless, the mean number of visits in this, as in a second, larger study,‘” did not differ by gender, confirming Garfield and Affleck’s” earlier conclusion that length of therapy is unrelated to patient sex. In Kirshner, Hauser, and Genack’s satisfaction with male or female patients interacted second study, 21’therapist significantly with other variables, including therapist experience and patient level of university training. However, the authors did find that female therapists were more satisfied with their female patients than therapists of any other pairing. Abramowitz et al.2’ also described a female therapist preference for female patients, speculating that “sex-role related countertransference” might be a factor for “less liberated” women therapists. Perhaps female patients are preferred because they do better in therapy than men. In their comprehensive review, Luborsky et aLp” found two studies in which women had superior outcomes versus none for males. Kirshner, Hauser, and Genack2” in the above cited study of 189 patient-therapist pairs at a university health service, also found that female patients showed a pattern of greater improvement than males, offering support for an hypothesis of a “patient gender effect” of greater responsiveness of women to psychotherapy. Moreover, the specific items in which females reported significantly more improvement than men attitudes toward career, academic motivation, academic performance, and family relations suggest gender-specific role conflicts attenuated in psychotherapy. Respondents in the latter study, like many other subjects, stressed their desire for an accepting, empathic therapist. Reports of previous investigations suggest that they would be more likely to find these traits in a female therapist. The work of Hill,” Howard, Orlinsky, and Hill,‘” and Kirshner, Hauser, and Genack”’ is consonant with a “therapist gender effect” of greater patient satisfaction and jmprovement with female therapists. Mendelsohn and Rankin’” speculated that females may simply be more sensitive to interpersonal behavior tham males. In fact, matching of female patients with female therapists failed to produce significant advantages in the above studies. indicating that other factors besides genderrelated personality traits are involved. University women, for example, tend to come for help at an earlier stage of their distress than men. Differences between male and female psychiatrists may say something important about selection of medical students and role pressures upon them, as reviewed by Light2” and documented impressively by Cartwright.‘” These authors suggest that female medical students, rather than women in general, are more likely than males to have traits desirable in a psychotherapist. In conclusion, gender appears to play as diverse and complex a role in

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psychotherapy as in other domains of life. Systematic influences of gender stereotypes, however, have proven difficult to document, with our limited data tending to minimize their impact. At least therapists seem largely able to limit the expression of their biases in gender as in other areas. On the other hand, findings supporting female patient and female therapist gender effects suggest that treatment of males and creation of productive therapeutic relationships by male therapists may represent significant areas of weakness for psychiatry. Finally, both in the individual case and in research studies, gender continues to deserve close attention as a major, if elusive, variable in therapeutic interaction. REFERENCES I. Gove WR, Tudor JF: Adult sex roles and mental illness, in Huber, J (ed): Changing Women in a Changing Society. Chicago, Ill., University of Chicago, 1973, pp 50-73 2. Kubie L: Practicai and Theoretical Aspects of Psychoanalysis. New York, International Universities, 1950 3. Mintz J, Luborsky L, Auerbach A: Dimensions of psychotherapy: a factor analytic study of ratings of psychotherapy sessions. J Consult Clin Psycho1 36: I06 120. 197 I 4. Gauron E, Dickinson .I: The influence of seeing the patient first on diagnostic decision making in psychiatry. Am J Psychiatry 126: 199-205. 1969 5. Koran L: The reliability of clinical methods, data and judgments. New Engl J Med 293642.-646, 1975 6. Broverman IK, Broverman DM, Clarkson FE, et al: Sex role stereotypes and clinical judgments of mental health. J Consult Clin Psycho1 34:lm7, 1970 7. Thompson C: Notes on the psychoanalytic significance of the choice of analyst. Psychiatry I:2055216, 1938 8. Steinmann A: Cultural values, female role expectancies and therapeutic goals: Research and interpretation, in Franks V, Burtie M (eds): Women in Therapy. New York, Brunner/Mazel, 1974, pp 5 l-82 9. Fabrikant B: The psychotherapist and the female patient: Perceptions, misperceptions, and change, in Franks V, Burtle MA (eds): Women in Therapy. New York, Brunner/Mazel, 1974, pp 83-l 10 LO. Schwartz J, Abramowitz S: Value-related effects on psychiatric judgment. Arch Gen Psychiatry 32:1525-1529, 1975 11. Abramowitz S, Roback H, Schwartz J, et al: Sex bias in psychotherapy: A failure to confirm. Am J Psychiatry 133:706-709,1976 12. Howard Kl, Orlinsky DE, Hill JA: The therapists’ feelings in the therapeutic process. J Clin Psycho1 25:83-93, 1969 13. Howard KI, Orlinsky DE, Hill JA: Patients’ satisfactions in psychotherapy as a

function of patjent-therapist Psychotherapy 7:130-134, 1970 14. Hill C: Sex of client

pairing. and

sex

and

experience level of counselor. J Consult Psycho1 22:5--l i, 1975 15. Davidson V: Patient attitudes toward sex of therapist: implications for psychotherapy, in Cleghorn J (ed): Successful Psychotherapy. New York, Brunner/Mazel, 1976 16. Chesler P: Patient and patriarch: Women in the psychotherapeutic relationship, in Gornick V, Moran BK (eds): Woman in Sexist Society. New York, Basic Books, 197 I 17. Williams J: Patients and prejudice: Lay attitudes toward women physicians. Am J Social 51:283-287, 1946 18. Jackson AM: Problems experienced by female therapists in establishing an alliance. Psychiatr Annals 3:6-9, 1973 19. Kirshner LA, Hauser ST, Genack A: Male and Female Freshmen in a University Mental Health Clinic. Unpublished study, Harvard University Health Service, 1976 20. Kirshner LA, Hauser ST, Genack A: Effects of gender on short-term psychotherapy. Psychother Res Prac, 1976 (in press) 21. Garfield SL, Affleck DC: An appraisal of duration of stay in outpatient psychotherapy, J Nerv Ment Disord 129:492-498, 1959 22. Abramowitz S, Abramowitz C, Roback H. et al: Sex-role related countertransference in psychotherapy. Arch Gen Psychiatry 33:71-73, 1976 23. Luborsky L, Auerbach A, Chandler M, et al: Factors in~uencing the outcome of psychotherapy: A review of quantitative research. Psycho1 Bull 75: 14% 148, 197 1 24. Mendelsohn GA, Rankin NO: Clientcounselor compatibility and the outcome of counseling. J Abnorm Psycho1 74:157-163. 1969 25. Light DW: The impact of medical school on future psychiatrists. Am J Psychiatry 132:607-610, 1975 26. Cartwright L: Personality differences in male and female medical students. Psychiatry Med 3:213-219, 1972