In a Glimpse of an Eye

An Exploratory Study on First Impressions in Psychotherapy


By Alexandra Freches Duque
Egas Moniz Multidisciplinary Research Center in Health Psychology, Portugal

The Art of Psychotherapy gives shape to a two egos’ dance, egos which constantly move and interact together as in a mirror image. Despite the fact that a psychotherapist leads the pair, each element involves itself in the interaction and recreation of every step. The dance and influence are drawn at each and every second and built through multiple interactions that an untrained eye may not see. It’s the milliseconds of a muscular contraction, catching a glimpse of a look, the blink of an eye, the moment of a verbal interaction… it´s the verbal and the non-verbal, it´s the conscious and unconscious…

In daily interactions, a significant part of the communication is done through body language, expressed in gestures and body postures socially assimilated and codified (Lopes, 2000). The first and most intense impressions about a person are formed during the first five seconds of contact, while 50% of the positive or negative impressions are formed during the next five minutes (Newman, 2004). All this amount of information is based on a transmission of emotional characteristics at the unconscious level, based on the signs given by the interlocutor. So, as in other daily interactions, the first moments of a psychotherapeutic encounter give rise to first impressions, shaped by a transmission of unconscious emotional characteristics and based on the signs provided by both egos that complete the interaction. The available literature says that, in the first seconds of an appointment with a new patient, psychotherapists tend to form an impression of the likely diagnosis and of the difficulties they will face throughout the therapeutic process. The same literature points out that many cues about the patient (e.g., cues provided by the person accompanying the patient, greeting styles, the patient’s dress choices or the way the patient speaks) seem to influence the process of establishing that first impression (Morrant, 1981). Typically, the first impression is accurate, and it correlates positively with the assessment the therapist makes at the end of several hours spent with the patient (Morrant, 1981).

Psychotherapists are, in fact, experts regarding observation, verbal and non-verbal communication, as well as interpersonal relations within the therapeutic base. As such, they are beforehand (as well as during their ongoing clinical practice) trained in order to be able to draw their attention to certain “behaviour traces” that in such a way are associated to, and revealing of important characteristics of the individual under observation. Because they are less transferential than subsequent meetings, the initial encounter in the waiting room, as well as the initial word exchange, offer unique insights into the patient that should be carefully compared with subsequent impressions (Brockman, 1998).

Essentially, it seems that psychotherapists constantly utilize their adaptive unconscious, which is why, according to Gladwell (2005), they are always learning and using their snap judgments and first impressions. The first session in a therapeutic setting is like a game, during which its own rules are established and developed (Laungani, 2002). The first session therefore is,of crucial importance in several aspects, as it gives both the therapist and the patient the opportunity to know and evaluate each other and, at the same time, it gives data about the factors which both patient and therapist offer in their verbal and non-verbal actions,,and enables even the creation of a “predictive frame” of the therapeutic process, which has just begun (Morrant, 1981).

Although the importance of first impressions seems to be undeniable, its underlying mechanisms are not yet completely clear, as well as the use that patients and psychotherapists make of it. The decisions and instinctive reactions (in other words unconscious reasons) compete with all kinds of interests, emotions and similar feelings, reason why those decisions may be shaped by a steady set of clear reasons (projection, for instance). However, a comprehension process is never absolutely neutral; instead, it is highly controlled by a set of previous information, and at the same time it involves hints, intuitions and hypothesis (always based on the referred set of information) all the more, since the subject of understanding is a human being (Laungani, 2002) with all its greatness and complexity. So, Brockman (1998) emphasises the importance of a therapist’s first impression, on a patient, affirming that this must be kept in mind until it may be understood, since, first impressions have always a meaning, even if the psychotherapists cannot understand them right from the start.

In the present work, it is our intention to identify and analyse psychotherapists’ first impressions, as well as their applications during therapeutic process. In other words, we aim to understand to what extent the therapists’ first impressions are similar among different professionals with different degrees of professional experience (as well as personal). In order to do so, we’ve shown to psychotherapists two videos that
reproduce the first moments of a first session of a psychotherapeutic process. The two videos, with the duration of 1,5 minutes each, presented a male therapist, working with two patients, one male and one female, of similar ages. All three were actors working from scripts, the content of which included the verbal and non-verbal components. The actor-therapist was instructed not to speak in such a way as to reduce the influence on the therapists who were going to see the “sessions”. On the other hand, the role played by the actors was structured based on using the same verbal material, but, balanced by an opposite non-verbal “discourse” in order to control the effect of words in the formation of first impressions.

After being confronted with these stimulus-videos the psychotherapists were questioned about their first impressions on these actor-patients. So, as we will see, the data collected indicates the existence, utilization and importance of the psychotherapists’ first impressions in a clinical setting.

Sample Characteristics
As shown on Table 1., the sample was formed by 20 therapists, each having at least five years of clinical practice, as we consider that professional experience may be a significant variable influencing the formation of first impressions. Most are female (70%), have a clinical experience of 10 years or more (60%), have masters’ and/or doctoral degrees (50%) in their area of base formation (psychology) and describe their theoretical orientation as psychoanalytic (90%).

The present work reveals that the therapists, after a first contact with a patient, form first impressions about him, being the most of them caused by non-verbal behaviour.

On the other side, different therapists, with different personal and professional characteristics seem to share first impressions on the same stimulus-patients; as shown on Tables 2 and 3, it is even frequent, in present study, to come across common reports on first impressions among several therapists.

Tables 2 shows therapists’ first impressions regarding the female patient, suggesting that different therapists identified in this patient signs of Depression (60%) and Anxiety  (40%) beyond identifying the patient as being closed to the therapeutic relation (40%).

Tables 3 illustrates therapists’ first impressions regarding the male patient, suggesting that different therapists identified in this patient signs of Anxiety (70%) and Ambivalence (50%) as well as considering the male patient as being Too much at ease (40%).

In the current study, we also examined the importance of transferential and countertransferential processes. So, despite the fact that most of the answers are shared among therapists, some differences in the formation of first impressions have been verified, what means that, even though an identical evaluation of the patients among different technicians subsists, it seems that the same patients may give rise, in different therapists, to different countertransferential issues, which may deeply influence the formation of the first impressions.

As we can see in Table 4, regarding therapists’ countertransferential Issues regarding the female patient, therapists report Empathy (25%) and Will to Give Support (20%), and regarding therapists’ countertransferential issues regarding the male patient, as shown in Table 5, therapists report contradictory countertransferential issues, as 30% refer experiencing Empathy (30%) and 30% refer sensing No Empathy (30%).

It is then possible to verify that the most frequent answers, although not having a major frequency, are contradictory, as “positive” and “negative” feelings are presented with same or similar frequency, that is to say, the therapists’ countertransferential issues were not common, especially when the male patient is concerned.

When speaking of hypothetical clinical intervention with the patients, as well as of their expectations on the development of the therapeutic process and relationship, it seems that there is some kind of a consensus, in what the specific needs of these interventions are concerned.

As shown on Table 6, regarding female patient’s therapeutic relationship and process, the therapists identified the need to Clarify Transform/Translate (50%) the request as well as predicted a Difficult Therapeutic Relation (50%) and Difficult Therapeutic Process (45%).

As shown on Table 7, regarding therapists’ forecasts in what concerns the therapeutic relationship and process of the male patient, the therapists identified the Need to Define Complaint/Request (50%) and the Need of Exploration (40%), as well as predicted a Difficult Therapeutic Process (50%) and an Easy/Regular Establishment of a Therapeutic Relationship (40%).

So, the current study seems to confirm the importance of first impressions in psychotherapeutic setting.

According to some authors, first impressions are often and decisively shaped by attitudes and other stimuli displayed by the assessed subject. For some reason, such stimuli trigger memories of other individuals the assessor came in contact with, in their past, producing an effect of dejá connu (Noffsinger, Pellegrini and Burnell, 1983).Some studies report a vast number of stimuli capable of triggering such associations, examples of which include perceived tension in the face or lips, shape of the eyes and shape of the face (Noffsinger, Pellegrini and Burnell, 1983). These findings are also consistent with the results found in our study.

Along with association, other factors have also been emphasised: the role of transference, in that the assessor seems to define his impression of others through projections of his own previous experiences (Marcus & Holahan, 1994); and the role of countertransference, suggesting that the analyst should go back to his own unconscious, as a receiving organ, towards the patient’s transmitting unconscious (Freud, cit. in Leitão, 2003), making it possible to assume that the analyst’s unconscious understands the patient’s unconscious (Heimann, cit. in Leitão, 2003). So, the data of present work indicate the existence, utilization and importance of the therapists’ first impressions in a clinical meeting. Most therapists assume that, when making predictions concerning the therapeutic process and the patient’s history, they make use of their first impressions, either in the format of mental or written records; however, they do not discard the possibility that such predictions may be proven wrong, or that the patient may surprise them. All therapists who participated in the study, were conscious of this reality and have even acknowledged that it is the awareness of these “snap judgements” that allows these to be constantly controlled so that they don’t dazzle the therapist, giving instead tracks for new ways in the sphere of the therapeutic process. As a matter of fact, it seems to be important to take first impressions into account, either as intuition, or as a way of snap judgments, but moreover as guiding information.

Beyond the presented results, we found several variables that significantly affect therapists’ responses. The variable “presentation order” carried some influence – it seems to have altered the focus of attention and, consequently, the therapists’ sensations or feelings concerning each of the patients. For example, regarding the male patient, our data points towards a higher sensation of aggressiveness and an “excessive easiness” among those therapists who were first exposed to the video featuring the female patient, while those who saw the videos in the reverse order mentioned more often the feeling of anguish, despair, ambivalence, anxiety and “unavailability to interact”. So, our data seems to suggest a higher “sympathy”, or empathy, towards the patient (be it male or female) who is featured in the first video seen. A comparison between the two conditions showed that more negative sensations were reported when that same patient was featured in the video seen last. When examining the responses given according to the variable “sex of the therapist”,
we see that this factor may carry some influence on the therapists’ first impressions, for differences were found between the responses of male and female therapists. They were, however, isolated differences, which do not reflect opposite approaches or assessments of the patient. We can only state here that, as it happens with other personal characteristics, the therapist’s sex (or their gender experience) may direct their “clinical eye” to one of the patient’s most salient features instead of another, rather than conditioning the assessment and procedure towards the patient. For instances, concerning the female patient, male therapists mentioned more often that they felt her as more asthenic and sad, while female therapists focused on her “unavailability to interact”. As to the male patient, we have also seen noteworthy differences, i.e. compared with their female counterparts, male therapists seem to have privileged the patient’s “external attribution” and “low motivation”.

Our study shows that the variables “Professional Experience of the Therapist” and “Academic Training of the Therapist” have, as well, some influence in the responses.  This finding is supported by the reviewed literature which states that both the development of the relation and the therapeutic process are significantly influenced by the therapist’s technical abilities, professional experience, personality traits and selfknowledge
(Eizirik, 1995; Eizirik, Polanczyk, Schestatsky, Jaeger & Ceitlin, 2007; Kernberg, 2000; Mogul, 1982). In the current study, we saw that the more experienced therapists tend to mention more frequently such characteristics as “deep pathology”, “withdrawal”, “restraint” and “defence”, while less experienced therapists seem to focus their attention on the diagnosis of depression or on characteristics such as “arrogance”, “falsity” or “insecurity”. Moreover, the more experienced therapists resort more often to their first impressions when formulating metaphors and interpretations, while their less experienced colleagues tend to privilege the information obtained during the course of their first contact with the patient and through the patient’s verbal speech and/or tone of voice.

So, our study showed that the process of first impressions formation in psychotherapeutic context is not free from the influence of multiple variables (situational, personal, professional). We saw that therapists are capable of forming first impressions about their patients and that they exhibit a similar pattern as to the use they make of those impressions throughout the therapeutic process. Within our sample, the process of forming first impressions seems, on the one hand, to be an unconscious and uncontrollable process; on the other hand, therapists seem to be aware of it and also aware of the likely influence of such impressions in their relation with their patients. Therapists participating in this study have frequently mentioned the need not to assume their first impressions as unquestionable truths, underlining the need to keep an open mind and allow the patient to surprise them. They have also pointed out that it is necessary to gauge, understand and explore their first impressions during the session, and throughout the therapeutic process.

Regarding the general conclusions found in our study, we can say that this study indicates that therapists do form first impressions in the therapeutic setting and, while falling short of establishing complete correspondence among the different therapists’ first impressions, we saw that, on the whole, those impressions were not contradictory. Another general conclusion is related to the idea that first impressions among different therapists concern similar issues; they are based, for the most part, on the patient’s nonverbal behaviour; to a lesser extent, on patients’ incongruencies, mostly regarding the relation between non-verbal and verbal behaviour; and, at the end of spectrum, on the patient’s verbal discourse alone. We also found highly congruent answers as to the therapists’ general predictions on the development of the therapeutic process and relation. The disparity seen in the results stems only from differences at the level of instrumental prognosis, meaning that, different therapists present different “therapeutic projects and courses of action”, thus identifying and highlighting different needs of the patient. Moreover, the existence and significance of first impressions is acknowledged and stressed by the majority of those therapists who are cautious in making use of them; in other words, therapists take them to be an important starting point in the process of knowing and developing a relation with the patient. That said, therapists do not consider themselves to be experts in first impressions formation; they constantly reaffirmed the need not to lose contact with the “actual” patient, and not to act only on the basis of information obtained via “instantaneous judgments”. Thus, therapists in our sample often use data from their first impressions both in their evaluation of the patient and as a means to conceptualize the patient; however, they hardly use their first impressions as “therapeutic action”.

We can therefore conclude that, despite the undeniable significance of first impressions in the therapeutic process, such impressions should hardly be taken as credible “shortcuts”. As pointed out by the therapists, they are seen as cues, or working orientations, to be necessarily subject to further validation, interpretation, understanding and exploration, not only in the context of the therapeutic relation, but  also in the multiple contexts of the therapist himself, whose personal and professional variables carry significant influence in the process of first impressions formations in psychotherapeutic context.

“A cloud does not know why it moves in just such a direction
and at such a speed, it feels an impulsion…. this is the place
to go now.

But the sky knows the reason and the patterns behind all
clouds, and you will know, too, when you lift yourself high
enough to see beyond horizons.”

Richard Bach


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Alexandra Freches Duque is a Clinical Psychologist and holds a Master’s degree in Psychology (Psychotherapy), from University of Lisbon. As a clinical psychologist she works with adolescent and adult patients which undergo emotional difficulties. She is also a teacher in the field of Health Communication and Health Psychology, and a researcher at Egas Moniz – Multidisciplinary Research Center in Health Psychology. She has participated in several research projects and has presented and published papers at national and international conferences and journals.

Alexandra Freches Duque

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