process differences between male and female therapists in a first family interview

Journal of Marital and Family Therapy 1992, Vol. 18, No. 2, 143-151

PROCESS DIFFERENCES BETWEEN MALE AND FEMALE THERAPISTS IN A FIRST FAMILY

INTERVIEW

Cleveland G. Shields Susan H. McDaniel University of Rochester

This paper reports a study of 63 initial interviews of structural-strategic therapy with families with child-focused problems. These interviews were analyzed to determine differences in the process of therapy between male and female therapists. We tested specifically for differences in joining and executive skills between male and female therapists. Transcripts made from audiotapes of the interviews were coded with the Therapeutic Interaction Coding System (TICS). Thirty- seven cases completed therapy, and 26 dropped out of therapy against therapists’ advice. There were no significant differences in male and female therapists’ case completion rates. The overall level of supportive statements was not significantly different between males and females. Family members made more structuring or directive statements toward male therapists, but stated more disagreement with other family members when their therapist was female. Male therapists made more explanation statements than female therapists in response to family members’ structuring or disagreement statements. In addition, we tested for differences in activity level and found that male therapists made more statements overall than did female therapists.

Much has been written recently about gender issues in family therapy, particularly with regard to therapists’ values (Hines & Hare-Mustin, 19801, the reification of the traditional family in family therapy theory (James & McIntyre, 19831, the application of feminist tenets in family therapy practice (Hare-Mustin, 1978a; Libow, Raskin, & Caust, 1982; Goldner, 1985; Taggart, 1985; Luepnitz, 1988; Walters, Carter, Papp, & Silverstein, 1988), and sexism in family therapy research (Gurman & Klein, 1981; Hare- Mustin & Maraceck, 1988). The special issues of women in family therapy training (Caust, Libow, & Raskin, 1981; Reid, McDaniel, Donaldson, & Tollers, 1987) have also received attention.

The effect of gender issues and feminism on all the psychotherapies has been the topic of important political, philosophical, and even technical debate. However, little methodologically sound research has been done in this area. Research on sexism in individual psychotherapy has focused on issues such as clinicians’ standards of mental health for male versus female patients (Broverman, Broverman, Clarkson, Rosenkrantz, & Vogel, 1970; Smith, 1980), patients’ gender preferences in choosing a therapist

We would like to thank Judy Myers Avis, PhD, for her helpful comments on an earlier version

Cleveland G. Shields, PhD, is Assistant Professor of Family Medicine and Psychiatry, Univer-

Susan H. McDaniel, PhD, is Associate Professor of Psychiatry and Family Medicine, University

of this paper.

sity of Rochester School of Medicine and Dentistry, 885 South Avenue, Rochester, NY 14620.

of Rochester School of Medicine and Dentistry, 885 South Avenue, Rochester, NY 14620.

April 1992 JOURNAL OF MARITAL AND FAMILY THERAPY 143

(Walker & Stake, 1978; Greenberg & Zeldow, 1980), mother-blaming in clinical journals (Caplan & Hall-McCorquodale, 1985), and the treatment of incest survivors (Armsworth, 1989). Studies of individual psychotherapy have examined the relationship between therapist gender and outcome. Three reviews in the 1970s (Meltzoff & Kornreich, 1970; Garfield, 1978; Parloff, Waskow, & Wolfe, 1978) found no clear relationship between these two variables. One study from 1980 by Orlinsky and Howard, re-analyzing data from 1965-67, tended to favor female therapists’ outcome over that of male therapists, especially with certain diagnostic categories such as anxiety reactions. Woodward et al. (1981) found that female therapists tend to underestimate their influence on families and rate their families as having changed less in treatment and as having poorer prognoses than do male therapists (in spite of objectively similar outcomes). In the family therapy literature Avis and Haig (1988) found many instances of mother-blaming in family therapy journals.

In this study we are interested in how the gender of the therapist affects the process of psychotherapy, in particular the similarities and differences in how men and women define and enact their roles as family therapists. Cultural sex role typing would suggest some systematic differences between men and women in how they behave as therapists. Reid et al. (1987) suggested that male family therapy trainees are more likely to do well with executive skills and to have difficulty with joining skills, and female family therapy trainees are more likely to be skilled at joining and to have difficulty with executive skills. This theory fits with sex role stereotypes and in fact has found some support in the research literature. A study of counseling trainees, presumably students seeing individual clients, did find that female trainees were warm and nurturing though significantly less confident, directive, and interpretive than males and that male trainees were both directive and nurturing (Yogev & Shadish, 1982). In a family therapy study that looked at therapy process in relation to therapist gender, Mas, Alexander, and Barton (1985) found that therapist gender has a significant impact on family therapists’ and family members’ verbalizations in the first sessions of family therapy. They found that adolescents spoke much less with female therapists than with male therapists, that male therapists used an affective (as opposed to behavioral or cognitive) mode of expression significantly more than female therapists, and that mothers and adolescents used different modes of expression depending on whether the therapist was male or female. Interestingly, the Mas et al. study (1985) found that the fathers’ type of communication was independent of therapist gender.

To study these issues further, we decided to test for differences between male and female therapists in the process of a first family interview. In this study we examine not only the frequencies of therapist behavior, but also the responses of therapists to family member behavior, the responses of family members to each other, and the responses of family members to therapists. It is the study of these interactions, and not just frequencies of therapist behavior, that makes this a study of the process of therapy.

We hypothesized that there would be significant differences between male and female therapists in their use of joining and executive skills. Specifically, we predicted that female therapists would use joining behaviors at a higher rate than male therapists, and that male therapists would use executive behaviors a t a higher rate than females.

METHODOLOGY

Design This research is a post hoc groups design. Cases were assigned to therapists on the

basis of availability, a common method of assignment (e.g., see Stanton & Todd, 1982). There is no reason to believe that there was any systematic bias in how cases were distributed, other than the therapists’ schedules.

144 JOURNAL OF MARITAL AND FAMILY THERAPY April 1992

Data The data used in this study were originally collected by Bostwick (1981). He collected

data on 74 different families who were seen by 22 different therapists in the family therapy program at the Institute for Juvenile Research in Chicago, Illinois. The therapists were trained in structural-strategic therapy (Liddle, Bruenlin, Schwartz, & Con- stantine, 1984). Sixty-three transcripts of the initial interviews were prepared by divid- ing audiotapes of the interviews into four sections and transcribing four 5-minute segments. Only the transcripts were available for coding; therefore, only the verbal behavior of therapists could be coded. The nonverbal information was not available. All of these cases were child-focused problems. Of these 63 initial interviews, 33 interviews were conducted by men and 30 were conducted by women.

Therapists rated each case as completers or noncompleters. (No data was available on resolution of presenting problems.) Completer cases were families that the therapist coded as staying in therapy until both therapist and family agreed it was time for the family to terminate treatment. Noncompleter cases were cases that either did not return for a second session or cases that returned for additional sessions but later discontinued therapy against therapist advice. There was no assessment of the reliability of therapists’ coding of cases as completer or noncompleter. However, in a previous study Shields, Sprenkle, and Constantine (1991) found numerous process differences between completer and noncompleter cases. We believe this demonstrates that the completer/ noncompleter categories have some validity as an outcome measure.

Measurement Instrument and Reliability The Therapeutic Interaction Coding System (TICS) (see Table 1) and a coding

manual were developed as part of this research project. In this coding system the unit of classification is a single thought. The units of analysis are simple and conditional probabilities. This method measures and analyzes systems level variables (Fisher, 1982; Fisher et al., 1985; Gottman, 1982; Rogers, Millar, & Bavelas, 1985; Shields et al., 1991). TICS is a highly reliable coding system. Kappa was .73 for therapist codes and .68 for family codes. For additional information on reliability see Shields et al. (1991).

Table 1 Therapeutic Interaction Coding System (TICS)

Therapist Verbal Codes

(1 EXP-ExploringITracking (2) STR-Structuring (3) DIR-Directing (4) AG-Agreement (5) DG-Disagreement (6) SUP-Supportiue (7) PXP-Problem-Explanation (8) SXP-Solution ExplanationlGoal Information (9) SD-Self-Disclosure

Family Verbal Statement Codes

(1) SI-Social Information (Not problem or change) (2) PI-Problem Information (Not Positive Change) (3) SGI-Solution & Goal Informution (Positive change, previous solutions) (4) AG-Agreement (5) DG-Disagreement (6) STR-Structuring (7) SUP-Supportive


RESULTS

First, we tested for differences by therapist gender on several background factors: family variables (number of parents in household, age of parents, age of child, and income), completion or noncompletion of therapy, and therapist variables (age, degree, and experience). The purpose of these analyses was to see if other differences between therapists or their cases might account for process differences between male and female therapists. Second, we tested variables measuring verbal joining skills and executive skills for significant correlations with gender. Finally, we tested for differences in therapist verbal activity level in an attempt to explain some of the differences we found between male and female behaviors.

Background Variables and Completion Rate Table 2 shows the values of various background variables by therapist gender. Two

of these variables were significantly different across therapist gender: mother’s age and academic degree of the therapists. However, on all other measures there appears to be no other significant difference in the families or in the therapists. Mother’s age in itself (a 4-year difference) is unlikely to have an effect on therapy interaction. Although male and female therapists have different academic degrees, their experience level is not significantly different. In addition, there is no significant difference in the completion rate of cases between male and female therapists. This means that there was no significant difference between male and female therapists on outcome (i.e., completion rate).

Joining Skills To test the relationship between therapist gender and joining behaviors we looked

at supportive and exploratory statements on the part of therapists and social information talk on the part of family members. (See Table 3.)

There was no significant correlation between the simple probability of therapists’ making supportive statements P(TSUP) and therapist gender. There were no significant correlations between therapist gender and therapist supportive statements given family members talking both about problems and about social information to the therapist.

Executive Skills To test the relationship between therapist gender and executive behaviors we

defined executive behaviors as structuring statements by therapists or family members that attempt to direct or control the process and content of a therapy session. Structuring statements include statements dealing with administrative information, statements attempting to redirect the flow of conversation, statements instructing family members to practice a new behavior, statements of disagreement that direct conversation, and statements that explain the therapist’s view of a problem. We analyzed structuring statements of both family members and therapists. (See Table 3.)

There was a significant correlation between family members’ structuring statements to the therapist P(STRT) and therapist gender. This means that there was a greater probability of family members making structuring statements to male therapists than to female therapists during the initial interview. There was no significant correlation between family members’ structuring statements to each other and therapist gender.

The simple probability of family members stating disagreement with other family members P(DGF) had a positive and significant correlation with gender. This means that when the therapist was female, family members were more likely to express disagreement among themselves than when the therapist was male.

The simple probability of therapists’ structuring P(TSTR) and the conditional probability of therapists’ structuring when family members structure or disagree with each


Table 2 Sample Demographics Broken Down by Therapist Gender

Variables Therapists Therapists P value Sig Male Female

Family Variables

I.P. Age

I.P. Sex Male

Mother Age

Mother Education (years)

Father Age

Father Education (years)

Income3

I.P. Race

Female

Caucasian Black Hispanic

Composition Single Mother Head Couple Head

Completer Cases Noncompleter cases

Completion Rate

Therapist Variables

Age

Degree BA MSW, MSSW MA PhD

Years of Experience Anv TheraDv

11.8 (4.7)

16 14

38.6 (8.0)

11.7 (2.2)

42.4 (9.9)

10.8 (4.1)

7.7 (5.1)

16 9 5

13 17

16 ' 14

31.2 (5.2)

5 3 2 18

10.4 (10.1) .I

Family Therapy 3.8 (1.8) 'T-Test 'X2 Test 3each point represents a $1,000 increment (Standard Deviation)

12.1 (6.4)

21 12

34.1 (7.1)

11.8

38.8 (10.1)

11.5 (3.6)

8.2 (4.9)

15 13 5

16 17

21 12

31.9 (10.1)

16 3 9 4

8.3 (7.8)

.80'

.412

.021

.91'

.30'

.63l

.701

.73'

.68'

.412

.701

.0012

.301

n.s.

n s . ** n s .

ns.

n.s.

n.s.

n.s.

n.s.

n.s.

n.s. **

n.s. 2.8 (4.2) .30' n.s.

other P(TSTR/STDF) had nonsignificant correlations with therapist gender. The conditional probability of therapists' structuring when family members structure or disagree with the therapist P(TSTR/STDT) has no significant correlation with gender. The conditional probability of therapists' giving explanations when family members structure or disagree with them P(TPXP/STDT) has a negative and significant correlation. This means that male therapists were more likely than female therapists to give explanations in response to a family member structuring or disagreeing with them.

Tests for Differences in Activity by Gender Since male therapists were more active on executive verbal behaviors, we decided

to test (post hoc) if there was a difference in activity level between male and female

April 1992 JOURNAL O F MARITAL AND FAMILY THERAPY 147

Table 3 Description Statistics and Correlations with Therapist Gender

Variable Gender Mean (SD) r sig.

Joining

P(TSUP)'

P(TSUP/PIT)'

P(TSUP/SIT)'

Executive

P(STRT)

P(STRF)

P(DGF)

P(TSTR)*

P(TSTR/STDF)'

P(TSTR/STDT)I

P(TPXP/STDT)

M F

M F

M F

M F

M F

M F

M F

M F

M F

M F

1.23 (1.08) 0.94 (0.72)

1.72 (2.01) 0.95 (1.25)

4.01 (9.4) 1.23 (2.3)

Family Member Behaviors

8.26 (8.50) 4.61 (4.12)

5.76 (5.2) 9.72 (0.9)

1.35 (1.78) 1.68 (2.00)

Therapist Behaviors

5.56 (2.53) 5.27 (3.88)

13.59 (14.44) 10.41 (15.26)

11.39 (19.84) 5.44 (6.44)

4.98 (7.45)

+ 0.157

- 0.229

- 0.210

- 0.272

- 0.184

+ 0.293

- 0.107

-0.118

- 0.203

n.6.

*

*

**

n.s.

**

ns .

n.s.

*

** 0.69 (2.24) - 0.375

Key: Superscript: =Log transform * * p 5 .05 * p 5 .10

therapists. We hypothesized that there were some behaviors on which female therapists had greater activity level. We tested for differences by gender on four activity variables: (a) total therapist statements, (b) total family member statements, (c) family member statements to therapists, and (d) family member statements to other family members. We expected the first variable to be higher for males and the other variables to be higher for females, so we conducted one-tailed t-tests. (See Table 4.) Only the total number of statements by therapists was significantly different by gender. Male therapists made more statements overall during therapy sessions than did female therapists.

DISCUSSION

In recent reviews of the state of the art in family therapy research, authors have emphasized the need for more studies of the process of family therapy (Wynne, 1988). Like most of the studies on therapist gender and individual therapy outcome, our study found no difference in the outcome of first family interviews conducted by men versus


Table 4 T-Tests on Frequencies of Therapist and Family Member Speech

‘Ma1 Number of Statements by Therapist

Gender N Mean (SD) T DF P Male 30 167.70 (52.23) Female 33 146.27 (36.62) 1.8989 61.0 0.0311

Total Number of Statements by Family Members

Gender N Mean (SD) T DF P

Male 30 261.96 (100.88) Female 33 244.60 (87.87) 0.7299 61.0 0.2341

Number of Statements by Family Members to the Therapist


Male 30 170.84 (66.02) Female 33 151.96 (33.48) 1.31 61.0 0.19

Number of Statements by Family Members to Other Family Members


Male 30 38.19 (35.55) Female 33 51.20 (49.72) .61 61.0 0.54

One-tailed t-test probabilities

those conducted by women. We did, however, find differences in the process of these interviews. The differences found appear to be consistent with differences found by other researchers in male and female communication patterns outside psychotherapy. (Henley, 1973, 1977) Family members may elicit different behavior from male versus female therapists because of their own gender-based expectations.

The major difference between the interviews conducted by men and those conducted by women was that male therapists talked more than female therapists. Male therapists were more verbally active than female therapists. This finding is consistent with Hen- ley’s (1973, 1977) research on male and female communication. She noted that the two most consistent findings were that men talked more than women in mixed gender groups and that men interrupted others more often than women did.

Taken as a whole, the results of our study indicate that male therapists tend to be more instrumental or directive than female therapists. Both the male therapists and the families they worked with seemed to engage in more of a “battle for structure’’ (Whitaker & Keith, 1981) than did the families with female therapists. Of course, this could be seen as an indication of the way female therapists join, that is, they don’t engage in as much of a “battle for structure’’ as male therapists do. Family members more often argued about the logistics or structure of treatment, tried to control the direction of the treatment, and disagreed with the therapist when the therapist was a man. And male therapists were more likely to respond to these challenges by directing family members or giving them an explanation than were female therapists. When the therapist was a woman, family members more often disagreed with each other, rather than with the therapist. These findings seem to fit with sex role typing for men and women in our culture, that is, people may feel more comfortable or even need to argue with male authority figures during an initial exchange and so develop symmetrical relationships with male therapists early on, whereas people may view female authority figures as more facilitative and so interact with them and each other in a more comple-


mentary fashion. Female therapists appear to encourage more discussion among families; male therapists appear to intervene more actively in family interaction than do female therapists.

Why are the male therapists more active verbally? One explanation may be that male therapists are more instrumental and take control of the family, whereas female therapists are more facilitative and allow the family to be themselves. Another may be that females attempt to structure or control initial interviews as much as males; theyjust do it nonverbally. We have no information on the nonverbal channel of communication. Perhaps the female therapists communicate nonverbally much of what is communicated verbally by the male therapists. We believe that these differences represent differences both in style and in gender socialization and that many different approaches may be effective in psychotherapy. To understand the process of psychotherapy, future studies should examine gender differences in both the verbal and nonverbal behavior of therapists.

These findings also raise questions for family therapy supervision research. What are the core skills that all family therapy trainees need to develop? Will male and female therapists exercise these skills differently, and do they then need to be supervised differently? Is gender-stereotyped behavior precipitated more by family members’ interaction with the therapist or more by therapist activity? Should we try to neutralize the effects of sex role socialization on therapy trainees or to encourage differences and awareness of differences? We hope our study will stimulate others to join us in pursuing these questions.

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