Article Review

R E S E A R CH A R T I C L E

How therapists' interpersonal behaviour is perceived by their patients and close others: A longitudinal and cross-situational study

Christine Wolfer1 | Peter Hilpert2 | Christoph Flückiger1

1Department of Psychology, University of

Zürich, Zürich, Switzerland

2Faculty of Social Sciences and Politics,

University of Lausanne, Lausanne, Switzerland

Correspondence

Christine Wolfer, MSc., Department of

Psychology, Division of Psychological

Interventions and Psychotherapy, University

of Zürich, Binzmühlestrasse 14/04, Zürich

CH-8050, Switzerland.

Email: [email protected].

Funding information

Swiss National Science Foundation, Grant/

Award Numbers: PP00P1_163702,

PP00P1_190083

Abstract

Due to their predictive abilities, therapist interpersonal behaviour is of great

relevance for psychotherapy. However, there is a lack of knowledge about its

stability inside but also outside of the therapy room within and between therapists.

The current study investigates interpersonal behaviour of trainee therapists (N = 20)

as perceived by four patients each suffering from generalized anxiety disorder and

three closely related persons of every therapist (close others). Investigating repeated

measures, four patients per therapist completed the Impact Message Inventory (IMI;

Kiesler, 1987) three times over the course of their cognitive behavioural therapy.

Furthermore, the IMI was completed by three close others at one assessment time.

Therapist interpersonal behaviour was perceived as more friendly and less submissive

when evaluated by close others compared to patients. Using a multilevel approach,

our results indicate that therapists' interpersonal behaviour was perceived

considerably stable across patients and over the course of treatment, and there is

considerable uniformity of the IMI evaluations in respect to the particular subscales

within and between therapists. Our results highlight the potential similarities of

observer-based habitual therapists' interpersonal behaviour inside and outside of the

therapy room.

K E YWORD S

impact message inventory, perceptions of therapists, therapists' effects, therapists' interpersonal behaviour, therapy research

1 | INTRODUCTION

“… therapists were people before they were professionals, …” noted

Wolf, Goldfried and Muran (2017, p. 175) in respect of therapists'

negative interpersonal responses, opening up to the question of the

origin of therapists' behaviours shown in treatment. Until today, it is

still mostly unknown whether therapist habitual interpersonal

behaviour is impacted more by a therapist's personal characteristics or

professional attitudes and roles. Furthermore, there is a lack of

knowledge about the stability of therapists' interpersonal behaviour

within and across life domains; therefore, the question arises if

therapists show comparable patterns when perceived by their

patients in comparison to the therapists' close others. Current

literature shows that therapist effects explain about 5%–8% (Johns

et al., 2019) of treatment outcomes and that some therapists are

about 10 times more effective than others (Okiishi et al., 2003).

Received: 18 November 2020 Revised: 9 June 2021 Accepted: 9 June 2021

DOI: 10.1002/cpp.2634

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any

medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

© 2021 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd.

Clin Psychol Psychother. 2022;29:289–298. wileyonlinelibrary.com/journal/cpp 289

However, only a few factors have been found to explain these effects

such as therapist personal burdens (Nissen-Lie et al., 2013), therapist

occupational burnout (Delgadillo et al., 2018), use of maladaptive cop-

ing strategies and self-doubt (Nissen-Lie et al., 2017), and therapists'

current alcohol-related and/or financial stress (Xiao et al., 2017).

Besides, therapists' perceived social support and degree of comfort

with attachment (Dunkle & Friedlander, 1996) are associated with

better therapy outcomes. Recent reviews emphasize in particular on

therapists' interpersonal variables (Heinonen & Nissen-Lie, 2020) next

to several interaction effects (Lingiardi et al., 2018). The alliance is

one such interaction between process and outcomes, where in an

analysis the therapists' contribution to the alliance was found to be

correlated to outcome but not the patients' contribution (Baldwin

et al., 2007; Del Re et al., 2021). Nevertheless, the personal character-

istics and/or professional skills that enable some therapists to estab-

lish better alliances and foster patient outcome have to be further

studied (e.g., Lingiardi et al., 2018).

Assessments of therapist abilities such as therapist interpersonal

skills have been found to predict psychotherapy outcomes of patients

up to several years (Anderson et al., 2015, 2016, 2009; Schöttke

et al., 2015). Those investigations of therapist interpersonal behaviour

refer to observer ratings in standardized assessment situations.

However, there is a lack of literature concerning the interpersonal

behaviour therapists habitually express while conducting psychother-

apy and its stability. Especially, literature about patients' perceptions

of their therapists' interpersonal behaviour is very limited. One of the

most prominent preexisting theoretical frameworks to understand

observer-based interpersonal behaviour in general is rooted in

Kiesler's (1979) interpersonal communication theory: the basis for his

theory is the interpersonal circumplex model (Freedman et al., 1951;

Wiggins, 1979) with the two central dimensions of affiliation and con-

trol (for an overview of names for these dimension, see Horowitz

et al., 2006); where the affiliation dimension contains the opposing

poles of hostility and friendliness and the control dimension contains

the opposing poles of dominance and submissiveness. According to

Kiesler, interpersonal behaviour of an individual (‘sender’) can be

assessed by the perceived experience evoked in his or her counterpart

(‘receiver’; see Schmidt et al., 1999). Thereby, it is assumed that first,

the sender is not entirely aware of his interpersonal style of communi-

cation and especially, its influence on his counterpart; second, the

interpersonal style of a sender's communication is experienced

similarly across different receivers; third, receivers are able to detect

their own internal response to the messages of a sender. Following

Kiesler (1979, 1983, 1987, 1996), it is a promising approach to

measure a sender's interpersonal behaviour by the receiver's internal

response. For this purpose, Impact Message Inventory (IMI; Perkins

et al., 1979) was developed, tested and translated into various

languages (e.g., Caspar et al., 2016).

Whereas Kiesler's theory and the IMI measure primarily were

developed to better understand patients' interpersonal behaviour,

some researchers expected that the interpersonal behaviour of the

therapists may be relevant as well (Goldfried & Davison, 1994;

Kiesler, 1979; Wolf et al., 2017). For example, in the Gloria Interviews,

the interpersonal behaviour of three prominent therapists could be

well differentiated using IMI assessment (Schmidt et al., 1999), dem-

onstrating a certain stability of an individual therapist's interpersonal

behaviour. In line, a study investigating the material of one of the pre-

viously mentioned assessments found a high internal consistency

(Cronbach's α = 0.94) of therapists' reactions across different patients

(Munder et al., 2019). Furthermore, it is widely assumed that thera-

pists' reactions are influenced by private experiences, indicating an

influence of personal experiences into the interpersonal behaviour in

therapy (e.g., Delgadillo et al., 2018; Gelso & Hayes, 2007; Rek

et al., 2018). Conversely, there is as well reason to assume that a

therapist's interpersonal behaviour may fluctuate between different

patients over the course of treatment. Accordingly, Carson (1969) for

example proposed ‘symptom-free individuals’ to be able to flexibly

and appropriately vary across interaction partners, enabling

nonpatients such as therapists to adapt to their vis-à-vis.

Furthermore, there are several treatment approaches that postulate

a flexible responsiveness of therapists' interpersonal behaviour

(e.g., Caspar, 2019).

Taken together, whereas the investigation of therapists' interper-

sonal characteristics recently got a particular focus in psychotherapy

research, there is still little knowledge about the potential variability

or stability of the therapists' habitual interpersonal behaviour as

perceived by their patients and their close others.

1.1 | Current study

The main aim of the current study was to investigate the therapists'

interpersonal behaviour in their professional as well as in their private

life (see Figure 1). More specifically, therapists' interpersonal behav-

iour was evaluated, each by four patients and three therapists' close

others using IMI measure. First, we tested the variability of the

therapists' interpersonal behaviour across all evaluators (Question;

Q1a), and we contrasted the patients' evaluations with those of the

close others (Q1b). Within the subsample investigating repeated

patients' IMI assessments (three patients' assessments during therapy,

Key Practitioners Messages

• Therapists' interpersonal behaviour is differently per-

ceived by patients compared to close others.

• Therapists' interpersonal behaviour is perceived as highly

stable across patients and over the course of treatment.

• A very low between-therapist variability of therapists'

interpersonal behaviour as perceived by their patients

emerged in this study, pointing to an unexpected high

homogeneity of interpersonal behaviour across the inves-

tigated therapists.

290 WOLFER ET AL.

four patients per therapist), we analysed the between-patient

differences (Q2a) and the within-patient variability over the three

assessment times (Q2b).

2 | METHODS

2.1 | Design

This study was a subproject of a larger randomized controlled trial

(RCT; study protocol: Flückiger et al., 2018). Cognitive behavioural

therapy in a 16-session format was provided for patients suffering

from generalized anxiety disorder (GAD). The therapy was delivered

according to the most recent Mastery Your Anxiety and Worry pack-

age (Zinbarg et al., 2006), which was developed to treat GAD and

entailed progressive relaxation or mindfulness, cognitive restructuring,

behavioural experiments as well as exposure (for more information of

the particular trial and the major outcomes, please see Flückiger

et al., 2021). Eighty patients who were randomly assigned to 20 thera-

pists were invited to evaluate the IMIs of their therapists at Sessions

5, 10 and 15. In addition, three therapist's close others completed the

IMIs as well (see Figure 1). In the patient sample, 72 out of 80 (90%)

IMIs returned at Session 5, 70 (87.5%) at Session 10 and 60 (75%) at

Session 15. In the close other sample, 51 out of 60 (86%) IMIs

retuned. Overall, for 14 (75%) therapists, there was no missing data

(i.e., 7 IMI evaluations per therapist). Data for this subproject were

collected from January 2017 until January 2020.

2.2 | Participants

2.2.1 | Therapists

Trainee therapists were recruited via announcements of the principal

investigator in therapist trainings. Twenty trainee therapists agreed to

participate in the superordinate project. Inclusion criteria were: (a) a

Master's degree in psychology and (b) being registered in an integra-

tive cognitive-behavioural psychotherapy-training programme. Of this

sample, 18 (90%) were female with an average age of 31.9 years

(SD = 6.9, range 28–56). The trainee therapists had been working as

therapists for 1.9 years (SD = 1.4, range 0–5), and their prior clinical

experience was on average 49 completed therapies (SD = 67, range

0–240).

2.2.2 | Patients

Patients were recruited via public announcements and adverts on

mailing lists. Inclusion criteria were (a) diagnosis of GAD assessed with

DSM 5, (b) being 18 years old or older, (c) informed consent and

F IGURE 1 Illustration of the study design and corresponding research questions 1 and 2

WOLFER ET AL. 291

(d) speaking German. Exclusion criteria were (a) suicidal tendency as

indicated by a score of 2 or higher on the corresponding item of the

Beck Depression Inventory, (b) medication for current bipolar or psy-

chotic disorder, or (c) current psychotherapy from another therapist.

Comorbidities as well as prescribed medications for mood disorders

did not lead to exclusion from this study. Eighty patients (75% female)

met inclusion criteria and their average age was 31 years (SD = 9.5,

range 21–67)

2.2.3 | Close others

Close others of the therapists were recruited by asking the therapists

to hand the questionnaires to three self-selected close others such as

family members, partners and close friends. To guarantee anonymity,

only age and gender were assessed. Close others of the therapists

were on average 36.7 years old (SD = 13.1, range 21–66) and 53%

female.

2.3 | Measures

Impact Message Inventory

Impact Message Inventory (IMI; Perkins et al., 1979) is an indirect

measurement of the interpersonal behaviour of a target subject in

which the interpersonal behaviour is rated by their interaction part-

ners (raters). Usually, the target subjects are patients and the raters

are their close others. However, in the current study, therapists are

the target subjects and they are rated by their patients and close

others. Raters evaluate their emotional, cognitive, and behavioural

experience in reaction to the target subject on a 4-point Likert-style

scale from ‘not at all’ (1) up to ‘very much so’ (4). The IMI is based on

interpersonal theories enabling investigators to draw interpersonal

styles by arranging interpersonal behaviour along the

interpersonal circle (Schmidt et al., 1999) with the two distinct dimen-

sions, control (submissiveness vs. dominance) and affiliation (hostility

vs. friendliness). Fingerle (1998) translated the shortened version into

German (IMI-RD; Fingerle, 1998). For the IMI-RD, alpha coefficients

ranged from 0.68 up to 0.86 (Caspar et al., 2016).

For the present study purposes, patients rated their therapist's

habitual interpersonal behaviour in therapy sessions. To take this par-

ticular situation into account, the IMI-RD was adapted. Items that

were unsuitable for therapy sessions such as “When I am with this

person, he/she makes me feel that… I should tell him/her to stand up

for himself” were not considered, and a total of 20 items were

retained. To ensure comparability, this adapted version of the IMI was

used for all participants. Psychometric properties of this shortened

scale were as follows: Cronbach's α ranged from α = 0.68 (hostile) to

α = 0.77 (friendly-submissive) with a mean alpha of α = 0.74 for the

subscales. The Kaiser–Meyer–Olkin (KMO) index returns an overall

MSA = 0.81 which is considered as meritorious (Kaiser, 1974) and

indicates a given suitability of data for factor analysis. The factor anal-

ysis yielded a comparative fit index (CFI) of 0.81 and a root mean

square residual (RMSR) of 0.089 indicating an adequate model fit. In

the current study, we decided to focus on the four main scales

(dominant, submissive, hostile, friendly). We tested if therapists differ

in their interpersonal behaviour in comparison to a patient population

collected in a Swiss university outpatient centre: therapists are per-

ceived as being significantly more dominant (t = �5.56, df = 311,

p < 0.001), more friendly (t = �3.82, df = 317, p < 0.001), and less

submissive (t = 11.98, df = 310, p < 0.001) than the outpatients and

they are seen as similarly hostile (t = 1.44, df = 317, p = 0.152).

2.4 | Data analysis

A multilevel modelling approach was used to analyse the nested data

(Raudenbush & Bryk, 2002). First, we investigated the variability of

therapist's interpersonal behaviour (Q1a) and tested whether thera-

pists' professional interpersonal behaviour is perceived differently by

their patients in comparison with therapists' private interpersonal

behaviour by three close others based on the four above-mentioned

scales (Q1b). These comparisons were tested using a multilevel model

where the group association (i.e., patients vs. close others) was added

as predictor at Level 1 and therapists as grouping variable at Level 2.

In order to test whether therapists' interpersonal behaviour varies

between patients (Q2a) and within patients over time (Q2b), a hierar-

chical multilevel model was performed for every scale with fixed inter-

cept and fixed slope. Five predictors were integrated into the model:

time, patient and therapist as well as their interactions time * patient

and time * therapist. Thereby, time as the repeated measure t1–t3 was

nested in patient at Level 2 which was nested in therapists at Level 3.

We used R statistical software for data preparation and statistical

analyses (R Development Core Team, 2014). In order to evaluate the

psychometric properties, Cronbach's α was calculated with the pack-

age psych (Revelle, 2018), and the package lavaan (Rosseel, 2012) was

used to compute factor analysis of the IMI. For hypotheses testing,

multilevel models were performed using the package lmerTest

(Kuznetsova et al., 2017).

3 | RESULTS

First, we investigated the variability of therapists' interpersonal behav-

iour (Q1a). Overall, therapists' interpersonal behaviour tends to be

perceived as friendly (M = 3.72, SD = 0.40, range = 1.8–4.0) moder-

ately dominant (M = 2.99, SD = 0.47, range = 1.0–4.0) and some-

what hostile (M = 1.57, SD = 0.39, range = 1–2.8); they may seem

somewhat submissive (M = 1.96, SD = 0.48, range = 1.0–3.3); the

standard deviations were noticeably low among patients and close

others and within patient at all three time points (a figure of every

therapists' individual ratings can be found in supplementary material).

Then, we compared patients' perceptions of therapists' interpersonal

behaviour with the therapists' close others' perceptions (Q1b). Results

revealed that patients compared to close others experience therapists

as significantly less friendly (t = 3.8, df = 85, p < 0.001) and less

292 WOLFER ET AL.

submissive (t = 6.26, df = 19, p < 0.001), but no significant differ-

ences were found in the hostile and dominant scales (see Table 1 and

Figure 2).

Second, we investigated whether patients perceived their

therapists' interpersonal behaviour differently (i.e., between-patient

differences; Q2a) and whether patients' perception of their therapists'

interpersonal behaviour fluctuated over time (i.e., within-patient

variability; Q2b). Results indicated no significant differences between

patients in any of the four scales at any point of time (see Table 2).

These findings indicate that therapists' interpersonal behaviour was

perceived similarly across patients. Finally, we tested whether

patients' perceptions of their therapists' interpersonal behaviour

varies over time (Qb2). Results did not show any significant main

effect for therapist nor a significant main effect for time in any of the

four scales. This indicates that patients experience therapists' inter-

personal behaviour as highly stable over the course of treatment. But

we found significant interactions of patient and Time3, indicating that

for some patients the perception of their therapists' interpersonal

behaviour changed from Time1 to Time3. Those patients perceived

their therapist as significantly more hostile, significantly more domi-

nant and significantly less friendly at Time3 compared to Time1. All

three effects were small as indicated by effect sized below Cohen's

ds = 0.5 (Cohen, 1998).

4 | DISCUSSION

The current study investigated therapist interpersonal behaviour

evaluated with IMI by patients and close others. We found small but

statistically significant differences of patients' and close others'

perception of therapists' friendliness and submissiveness. Similar

differences in therapists' interpersonal behaviour between personal

and professional relationships emerged when therapists rated

themselves: in a study conducted by Heinonen and Orlinsky (2013),

therapists reported showing more warmth, nurturance, protection and

intuition in personal than in professional relationships. Fincke, Möller

and Taubner (2015) found that therapists indicated being more

affiliated to and less controlling in personal compared to professional

relationships. There are several differences between patients and

close others that could have led to this result: first, close others are

relatives of the therapists as most therapists reported having asked

family members, partners and good friends, whereas the patients

knew their therapists from their therapy sessions only. Therefore,

close others could have rated the therapists towards social desirabil-

ity. Second, close others were self-selected by the therapists, whereas

the patients were randomly assigned by the study protocol. Hence, it

is possible that therapists chose only those persons of whom they

assumed to be especially positively inclined towards themselves.

However, there is little knowledge about whether these close rela-

tives evaluate the therapists differently from other relatives that are

not selected from the therapist. Third, the relationship qualities in

close relations can be assumed to be reciprocal (Patterson

et al., 1993) and driven by emotional needs (Heinonen &

Orlinsky, 2013), whereas, within therapy, the therapist is assumed to

be primarily focused on his or her patient (Norcross & Hill, 2002). Fur-

thermore, the therapeutic context itself may impact the IMI evalua-

tions. As therapists may have an active role in leading the process of

change, they may be perceived less submissive. Moreover, as thera-

pists may sometimes have to address uncomfortable, unpleasant or

painful topics which were avoided by the patients, they may be per-

ceived as less friendly and more dominant by their patients.

In respect to the therapeutic context (within- and between

patients), we found no substantial variation and significant differences

in the perception of the therapists' habitual interpersonal behaviour. A

similar result was obtained in an investigation with depressive

patients, where therapist IMI change could not be assessed due to

restricted variability (Coyne et al., 2018). In our study, only a small

interaction effects with time emerged for a few patients, indicating a

change in their perception of the interpersonal behaviour of their

therapist. These patients rated their therapists as more hostile, more

dominant and less friendly at the end of treatment compared to the

beginning. One explanation could be that—as outlined above—

therapists had to address unpleasant topics to the patients, which let

the patients change their perception over the course of treatment.

However, similar deteriorations with slightly less friendly and more

hostile interpersonal behaviour have as well been documented in the

Vanderbilt II study, where these effects were attributed to the investi-

gated manualized psychodynamic training (Henry et al., 1993).

Most strikingly, however, the variances between all perceptions

of the therapists were noticeably low. Hence, the results seem to

TABLE 1 Therapists' interpersonal behaviour perceived by close others compared to patients

Close others Patients Difference

IMI scale M (SD) M (SD) Mdiff (SE) t (df) p

Hostile 1.56 (0.38) 1.46 (0.37) �0.10 (0.07) 1.47 (45.30) =0.147

Dominant 2.99 (0.42) 3.06 (0.47) 0.07 (0.09) 0.71 (21.76) =0.482

Friendly 3.73 (0.29) 3.51 (0.33) �0.22 (0.06) 3.80 (84.66) >.001***

Submissive 1.96 (0.52) 1.34 (0.36) �.62 (0.10) 6.26 (19.06) >.001***

Abbreviations: df, degrees of freedom; M, mean; SD, standard deviation; SE, standard error; t, test statistic

of the linear mixed model. *p < 0.05. **p < 0.01. ***p < 0.001.

WOLFER ET AL. 293

speak for a relatively homogeneous perception of the interpersonal

style for all therapists rather than an individual therapist's personal

style or individual adaptation/responsiveness (see Supporting Infor-

mation). We only can speculate about this unexpected high stability

of perceptions of the therapists across patients and time. Reasons

may lay in the therapists themselves, in the present study context as

well as in the IMI assessment: first, therapists decided to become a

mental health professional and they pursued this career for quite

a while. Next, they decided for cognitive-behavioural therapy post-

graduate training, were selected by the training centres and agreed to

participate in an RCT. Overall, this may have reduced the diversity of

interpersonal styles in the professional psychotherapy context.

Indeed, in the stereotype literature, it is assumed that people use ste-

reotypes of professions as guidance to their vocational choice and

that self-concepts are positively correlated to the stereotype of their

profession (Hollander & Parker, 1969). Furthermore, hiring decisions

have been shown to be influenced by stereotypes (e.g., Nadler &

Kufahl, 2014); that is, the training centres as well may have chosen

their trainees based on congruencies with a psychotherapists' inter-

personal stereotype. Additionally, stereotypes affect subsequent per-

ceptions of people (Cohen, 1981). It is well known in the literature

that memory-based ratings are often relied on abstractions such as

stereotypes (Srull & Wyer, 1989). Therefore, the therapist stereotype

of patients and close others may as well have influenced IMI ratings.

Partly in line with our finding of therapists being perceived as moder-

ately dominant, friendly, not hostile and somewhat submissive, an

investigation by Levy (1988) found the stereotype of a therapist was

perceived more as leader than as a follower, warm, concerned with

others and relaxed. Moreover, one could even argue in the sense of a

déformation profesionnelle, a French term used to describe the effect

of an (over-) internalization of the professional role which leads to the

usage of professional perspectives and practices in everyday lives

(Rey, 2008). Indeed, an interview study investigating the effects of

practice on the personal life of therapists found that over 70% of the

investigated therapists perceived themselves to act therapeutically

outside practice (Farber, 1983).

Second, the study context could have influenced the results. All

therapy sessions were videotaped within a manualized cognitive-

behavioural therapy approach (Zinbarg et al., 2006). The videotaping

could have led to ‘controlled’ and less spontaneous behaviours in

respect to general therapeutic skills and cognitive behavioural inter-

ventions. However, close others' perceptions of therapists were simi-

lar as well without those constraints.

Third, IMI assessment is based on Kiesler's circumplex theory and

its underlying assumptions (Kiesler, 1979, 1983, 1987, 1996). The first

assumption presumes that the ‘sender’ is not aware of his influence

on others. However, many would expect therapists to be aware of

their influence and impact on others (Caspar, 2019; Fauth &

Williams, 2005; Jennings & Skovholt, 1999; Stiles et al., 1998) and

therefore may be responsive to the others' perceptions in respect to

the therapists' preferences of how they would like to be perceived by

the others. The second assumption is that the sender's communica-

tion is experienced similarly across different receivers. This assump-

tion seems to be met by our results. The third assumption is that

‘receivers’ are able to detect their own internal response to a sender.

However, the receivers in this study were patients and therefore the

decoding of their therapists interpersonal behaviour may be distorted

by these individuals (Caspar et al., 2016), e.g., the shared characteris-

tics of patients that suffers from GAD. However, close others evalu-

ated the therapists as well, and (even if not tested) it is most likely

that these persons generally did not suffer from a GAD. Last but not

least, the perceived behavioural uniformity in the IMI assessment

F IGURE 2 Data distribution of ratings by close others and patients per IMI scale

294 WOLFER ET AL.

could represent an evaluative outcome rather than a behavioural indi-

cator. In other words, IMI evaluations could be a consequence of vari-

ous behaviours of therapists to get a favoured picture of themselves

in their patients, for example, via a therapeutic responsiveness. In any

case, it is unlikely that all therapists are just so responsive to individual

patients that eventually all patients come up with the same percep-

tion. Altogether, our results indicate an unexpected homogeneity in

the therapists' interpersonal behaviour as experienced and perceived

by their counterparts. Borrowing Wolf, Goldfried and Murans (2017)

words, one could also state: therapists are those people that became

professionals.

5 | LIMITATIONS

This study has some limitations. First, this study may lack generaliz-

ability as the sample consists of only German speaking therapists in

their early career. Second, part of the uniformity of this sample may

be due to selection effects of the study itself. Therapists were

enrolled in Swiss CBT training programmes and participated in the

RCT. Furthermore, we had to adapt the questionnaire for patients as

well as close others. Therefore, inappropriate items for one of each

context were not considered. Differences in therapists' interpersonal

behaviour may be found when assessed with more items and more

distinguished questions. However, we did find small effects. On the

one hand, a difference in friendliness and submissiveness between

close others and patients emerged and on the other hand an interac-

tion was found, indicating an increase in perceived hostility of some

therapist over the course of treatment. Last but not least, in the cur-

rent study, we used IMI assessment, which builds on the perception

of interpersonal behaviour. However, the behaviours themselves that

lead to a certain perception were neglected. Limitations notwithstand-

ing, results are compelling as they provide preliminary information

about potential variability of therapists' interpersonal characteristics

across multiple evaluators. The results obtained showed a decrease in

the perceived friendliness of the therapist for some patients, implying

the possible occurrence of negative events or developments over the

course of therapy. Furthermore, a uniformity-like stability is indicated

TABLE 2 Therapist interpersonal behaviour between and within patients

Patients

IMI scale Fixed effects γ SE t p Cohen's ds

Hostile Time 1 1.296 0.884 1.47

Time 3diff �1.098 0.989 1.11 = 0.27

Patient �0.001 0.001 0.54 = 0.57

Therapist 0.001 0.007 0.26 = 0.79

Patient * time 3 0.002 0.000 4.28 <0.001*** 0.32

Therapist * time 0.006 0.008 0.75 = 0.45

Dominant Time 1 2.930 1.35 2.16

Time 3 diff 0.967 0.953 0.91 = 0.36

Patient 0.000 0.000 0.03 = 0.98

Therapist 0.001 0.012 0.10 = 0.92

Patient * time 3 0.002 0.000 2.6 = 0.004 ** 0.21

Therapist * time 0.006 0.009 0.67 = 0.49

Friendly Time 1 3.577 0.971 3.68

Time 3 diff 1.425 1.066 1.33 = 0.18

Patient 0.000 0.000 1.18 = 0.24

Therapist �0.002 0.008 0.22 = 0.83

Patient * time 3 �0.003 0.000 6.25 <0.001*** 0.20

Therapist * time 0.006 0.009 0.68 = 0.50

Submissive Time 1 0.584 0.862 0.68

Time 3 diff �0.353 0.894 0.40 = 0.69

Patient 0.000 0.000 0.07 = 0.94

Therapist 0.007 0.008 0.91 = 0.37

Patient * time 3 0.000 0.000 1.43 =0.15

Therapist * time 0.002 0.008 0.28 = 0.83

Abbreviations: Cohen's ds, effect size after Cohen (1992) with pooled standard deviation; N, number of

participants; SE, standard error; t, test statistic of two-level hierarchical model; γ, predictor. *p < .05. **p < .01. ***p < .001.

WOLFER ET AL. 295

by the finding of an unexpected low variability of perceived interper-

sonal behaviour across all therapists, which implies an interplay of dif-

ferent unifying mechanisms such as selection, stereotypes and

adaptations.

For future research, it would be promising to use a combination

of assessments to understand interpersonal behaviour from different

points of view and in order to replicate the results obtained in this

preliminary investigation. Especially the investigation of possible mod-

erators of patients' perceptions of their therapists could add essential

information about therapist effects and may be an important link to

process research. Furthermore, studies with other patient and thera-

pist populations may provide estimates of the generalizability of the

effects. Thereby, studies with more experienced therapists may help

to get a more differentiated picture of therapists' habitual interper-

sonal behaviour. Last but not least, studies combining patient out-

come with perceived interpersonal behaviour of their therapist may

help to deepen the understanding of therapist effectiveness. How-

ever, such future direction would be particularly relevant for those

samples where the IMI data indicates less within and between unifor-

mity than in the present study.

ACKNOWLEDGEMENTS

We would like to thank the therapists for their willingness to partici-

pate and their openness to let their close others and their patients

rate them.

DATA TRANSPARENCY STATEMENT

There is no prior manuscript that analysed this set of data. Further-

more, there is no manuscript submitted or in pipeline that is based on

the present dataset.

FUNDING INFORMATION

This study was supported by the Swiss National Science Foundation

(Grants: PP00P1_163702, PP00P1_190083; principal investigator:

Christoph Flückiger).

DATA AVAILABILITY STATEMENT

Based on the requirement for patient's and therapist's confidentiality

and data security, the ethical guidelines of the randomized clinical trial

require to keep the raw data on an interne data storage at the

university of Zürich for 10 years. Anonymized data (without

descriptive patients', close others' and therapists' data to keep the

confidentiality) can be requested from the corresponding author.

ORCID

Christine Wolfer https://orcid.org/0000-0001-5804-7192

Peter Hilpert https://orcid.org/0000-0001-9424-3019

Christoph Flückiger https://orcid.org/0000-0003-3058-5815

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SUPPORTING INFORMATION

Additional supporting information may be found online in the

Supporting Information section at the end of this article.

How to cite this article: Wolfer, C., Hilpert, P., & Flückiger, C.

(2022). How therapists' interpersonal behaviour is perceived

by their patients and close others: A longitudinal and

cross-situational study. Clinical Psychology & Psychotherapy, 29

(1), 289–298. https://doi.org/10.1002/cpp.2634

298 WOLFER ET AL.

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