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Therapist Nonverbal Behavior and Perceptions of Empathy,

Alliance, and Treatment Credibility


Nia M. Dowell and Jeffrey S. Berman
University of Memphis
The aim of this study was to examine the potential independent and joint impact of 2
specic therapist nonverbal behaviorseye contact and trunk leanon perceptions of
therapist empathy, the relationship between client and therapist, and the credibility of
the treatment. Four different psychotherapists were lmed in 4 combinations of eye
contact and trunk lean. Participants rated these therapists after viewing a randomized
order of the therapy session videos. Findings indicate that high eye contact and forward
trunk lean enhanced perceived therapist empathy, therapeutic alliance, and treatment
credibility. These results suggest that therapists could improve their practice by using
specic nonverbal behaviors.
Keywords: psychotherapy, nonverbal behavior, empathy, therapeutic alliance, credibility
Nonverbal behaviors are viewed as a central
feature of interpersonal communication, with
interpersonal judgments and behaviors often
based on nonverbal cues (e.g., Hall, 2009). The
importance of nonverbal communication has
been assessed in a variety of interpersonal in-
teractions, including those between teacher and
student (Witt, Wheeless, & Allen, 2004), parent
and child (e.g., Edelstein et al., 2004), law en-
forcement ofcer and criminal (e.g., Mann,
Vrij, & Bull, 2002), and husband and wife
(Gottman & Notarius, 2000).
Nonverbal behaviors can also inuence the
interactions found in health care settings, such
as those between physician and patient. Studies
have found physician nonverbal behaviors to be
related to patient satisfaction and outcomes (see
Hall, Harrigan, & Rosenthal, 1995; Mast,
2007). For example, nonverbal behaviors such
as eye contact (Bensing, Kerssens, & Pasch,
1995), posture (Hall et al., 1995), and physician
tone of voice (Ambady et al., 2002) are associ-
ated with patient satisfaction of care, quality of
diagnosis, and physician malpractice claims his-
tory.
Similarly, nonverbal behaviors have been
found to play a role in psychotherapy. In the
psychotherapy setting, nonverbal behaviors
have been used to investigate aspects of thera-
peutic communication. Some research has fo-
cused on the nonverbal behaviors of the client:
For example, studies have examined gesturing
rates as a means of differentiating between psy-
chological disorders (Annen, Roser, & Brne,
2012) or head movements as an indicator of
client and therapist perceptions of therapeutic
progress (Hill & Stephany, 1990). Similarly,
research has assessed the relationship between
therapist nonverbal behaviors and variables
thought to be related to successful therapy. For
instance, increased therapist eye contact has
been found to be related to more positive per-
ceptions of the therapist in terms of rapport,
respect, empathy, and genuineness (Darrow &
Johnson, 2009; Fretz, Corn, Tuemmler, & Bel-
let, 1979; W. E. Kelly & True, 1980; Tepper &
Haase, 1978); more frequent therapist postural
shifts appear associated with greater client sense
of involvement (Kim, Liang, & Li, 2003); in-
creased therapist facial expressions of joy, in-
terest, and concern are correlated with greater
perceptions of rapport (Sharpley, Jeffrey, &
Mcmah, 2006; Tepper & Haase, 1978); and
This article was published Online First March 11, 2013.
Nia M. Dowell and Jeffrey S. Berman, Department of
Psychology, University of Memphis.
This research was supported by a Centers of Excellence
grant awarded to the Department of Psychology at the
University of Memphis by the state of Tennessee.
Correspondence concerning this article should be ad-
dressed to Jeffrey S. Berman, Department of Psychology,
University of Memphis, Memphis, TN 38152. E-mail:
jberman@memphis.edu
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Journal of Psychotherapy Integration 2013 American Psychological Association
2013, Vol. 23, No. 2, 158165 1053-0479/13/$12.00 DOI: 10.1037/a0031421
158
therapist leaning forward (Fretz et al., 1979;
Tepper & Haase, 1978), nodding (Claiborn,
1979; Darrow & Johnson, 2009), or gesturing
(Darrow & Johnson, 2009) all lead to more
positive ratings of therapists.
One factor important in considering nonver-
bal behaviors is the process by which an indi-
vidual comes to believe an interactional partner
understands, values, and supports key aspects of
the self, which has been termed perceived re-
sponsiveness (Maisel, Gable, & Strachman,
2008). The concept of perceived responsiveness
is a central issue in research on intimate inter-
actions. Although a variety of nonverbal behav-
iors have been studied in social interaction re-
search, eye contact and the angle of the upper
torso while seated seem to be particularly im-
portant in communicating responsiveness. In
line with this, eye contact and body lean are
frequently cited as behaviors that communicate
emotional responsiveness, involvement, and in-
terest (Burgoon, Buller, Hale, & deTruck,
1984). According to several recent reviews of
the literature, intimacy, trust, empathy, and at-
tachment all include this process of perceived
responsiveness (Lemay, Clark, & Feeney, 2007;
Murray, Holmes, & Collins, 2006; Reis, Col-
lins, & Berscheid, 2000).
In psychotherapy, responsive behaviors are
thought to communicate a therapists readiness
to receive and respond to the expressed needs of
a client during therapeutic interactions. It is
commonly accepted that high levels of eye con-
tact and body lean convey a responsive attitude,
whereas lower levels of eye contact and back-
ward body lean are associated with an unre-
sponsive attitude (Barak, Patkin, & Dell, 1982).
Research, in fact, indicates that therapist eye
contact and body lean have a substantial effect
on ratings of a therapist (Hall et al., 1995).
Most research on nonverbal behaviors in psy-
chotherapy has used videotaped segments of
therapy interactions and examined different lev-
els of therapist eye contact and body lean on
positive therapeutic qualities such as therapist
empathy (Tyson & Wall, 1983; Young, 1980),
genuineness (Graves & Robinson, 1976), trust-
worthiness (Claiborn, 1979), effectiveness
(Reade & Smouse, 1980), attractiveness (Fretz
et al., 1979), expertness (Barak et al., 1982;
Siegel & Sell, 1978), and persuasiveness (La-
Crosse, 1975). In general, these studies suggest
that body lean and eye contact are benecial to
perceptions of the therapist.
Past research on nonverbal behavior in psy-
chotherapy, with the exception of Tepper and
Haase (1978), has combined multiple nonverbal
behaviors at once rather than examining their
individual inuences. Because of this, it is dif-
cult to assess the role of specic behaviors in
communicating positive qualities of the thera-
peutic interaction. For example, effects attrib-
uted to therapist eye contact might be through
therapist co-occurring body orientation or head
nodding.
The aim of the present research was to alter
levels of therapist eye contact and body lean
independently as a way to assess their individ-
ual inuences on perceptions of therapist empa-
thy, therapeutic alliance, and treatment credibil-
ity. In the study, four experienced psychother-
apists were lmed in four combinations of eye
contact and body lean. Participants viewed a
randomized order of four therapy session vid-
eos. Following each video, assessments were
obtained of perceived therapist empathy, thera-
peutic alliance, and treatment credibility. Thus,
the research design allowed us to test not only
the individual effects of therapist eye contact
and body lean but also possible combined
effects.
Method
Therapists
The therapists in the videos (2 males, 2 fe-
males) were experienced faculty members from
the clinical psychology program of a large ur-
ban university. Two of the therapists reported a
cognitivebehavioral therapy orientation and
the other two therapists reported a constructivist
orientation. All therapists were Caucasian.
Pseudoclients
The clients in the videos (2 males, 2 females)
were undergraduate research assistants. The
mean age of the pseudoclients was 20.3 years
(SD 1.7, range 1822 years) and all were
Caucasian.
Therapist Training and Therapy Videos
Stimulus material consisted of brief (5-min)
role-play interactions between a therapist and
159 NONVERBAL BEHAVIOR AND PERCEPTIONS
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pseudoclient. Before recording a video, the ther-
apist was given a written description of the level
of eye contact and trunk posture to be used
during that video. After a therapist read the
protocol, the condition was demonstrated and
discussed with the therapist, and then lming
occurred. If during lming the therapist was
seen as not complying with the condition be-
haviors, recording of the video was restarted.
The therapy interactions and topics discussed
were unscripted. Each pseudoclient was in-
structed to develop different issues to discuss
with each of the four therapists. The presenting
problems in the sessions covered a variety of
topics such as grief and loss, anxiety, parent or
family conicts, depression, and life transitions.
The videos were lmed over the shoulder of
the client, showing a full front view of the
therapist. The therapist was seated in an arm-
chair opposite the client at a distance of 55 in.
(140 cm), which is considered to be neutral (see
F. D. Kelly, 1972, p. 345).
Each therapist completed four videos, one in
each of the possible combinations of high and
low eye contact and forward and upright trunk
posture. The order in which the four conditions
were lmed was counterbalanced across the
four therapists. In addition, the therapist and
pseudoclient dyads were varied systematically
to ensure that each therapist interacted just once
with each pseudoclient.
In the upright posture condition, the thera-
pists were in the seated position with their upper
torso in the upright position and holding a note
pad. In the forward leaning condition, the ther-
apists were in the seated position with their
upper torso leaning forward while holding a
note pad. In the high eye contact condition, the
therapists were asked to look directly at the
clients eyes most of the time; in the low eye
contact condition, they were asked to look
down at the note pad or away from the client the
majority of the time. The therapists body ori-
entation remained facing toward the client in all
stimulus interactions.
Participants
A total of 144 undergraduate students (73%
female) enrolled in introductory psychology
courses at a large urban university participated
in the study for course credit. Participant mean
age was 21.2 years (SD 5.7, range 1653
years).
Procedure
The study was conducted in a series of 46
sessions, with a mean of 3.1 participants (range
16) per session. Each session was held in a
classroom equipped with a screen and projector.
When participants arrived, they sat in the mid-
dle section of desks toward the front area of the
classroom facing the projection screen at the
front of the room. Participants completed a con-
sent form and were then told that they were
about to see a series of brief videos of therapy
sessions and after each one they would com-
plete a questionnaire.
Participants in each session viewed the video
recordings of the same therapist in each of the
four combinations of the eye contact and trunk
posture conditions. Following the presentation
of a video, participants completed a question-
naire and the researcher checked the completed
questionnaires for missing responses before
starting the next video. Once all four videos
were viewed and all questionnaires were com-
pleted, participants lled out a demographic
survey.
Participants in different sessions viewed dif-
ferent therapists and saw the four treatment
conditions in different orders. The sequence in
which the conditions were presented and the
therapist who was viewed were counterbal-
anced across the sessions to ensure that neither
order of presentation nor therapist was con-
founded with treatment condition.
Manipulation Check
The video interactions were examined to as-
sess whether eye contact and trunk posture con-
ditions varied as intended. This check con-
rmed that the number of minutes of eye con-
tact in the high eye contact condition (M 4.3
min) was higher than in the low eye contact
condition (M 1.1 min), t(14) 37.46, p
.001. The check also conrmed that therapists
maintained the required body position for the
entire time in each of the trunk posture condi-
tions.
Measures
Penn Helping Alliance Rating Scale. This
scale of therapeutic alliance consists of ve
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items assessing perceptions of therapist under-
standing and empathy (Alexander & Luborsky,
1987). In this study, the items were rated on a
10-point scale with labels of 1 very little, 3
some, 5 moderately, 7 much, and 10
very much. Because observers were completing
these items, the wording of the items was refor-
mulated to reect the perspective of an ob-
server. Reliability for the measure was high
across all four conditions (Cronbachs alpha
range .85.89).
Barrett-Lennard empathy items. The 16
empathy items from the Barrett-Lennard Rela-
tionship Inventory (Barrett-Lennard, 1962)
were used to measure perceptions of therapist
empathy. Each was scored on a 10-point scale
with labels of 1 very little, 3 some, 5
moderately, 7 much, and 10 very much.
Reliability for the measure was high across all
four conditions (Cronbachs alpha range
.84.91).
Treatment Credibility Expectancy
Questionnaire. This ve-item scale assesses
the perceived credibility of a treatment (Bork-
ovec & Nau, 1972). For this study, the items
were worded to reect their completion by an
observer. All items were rated on a 10-point
scale with labels of 1 very little, 3 some, 5
moderately, 7 much, and 10 very much.
Reliability for the measure was high across all
four conditions (Cronbachs alpha range
.95.96).
Statistical Analysis
The main analyses were carried out by means
of a 2 (eye contact level) 2 (posture level)
analysis of variance (ANOVA) in which both
eye contact level and trunk posture represent
repeated measures. The possible inuence of
orientation was examined by including therapist
orientation as an additional continuous indepen-
dent variable in the analysis model.
Analysis of possible effects of therapist sex
was conducted by means of a 2 (therapist sex)
2 (eye contact) 2 (trunk posture) ANOVA
in which both eye contact level and trunk pos-
ture represent repeated measures. In addition,
the assessment of participant sex was carried
out by a comparable 2 (participant sex) 2 (eye
contact) 2 (trunk posture) ANOVA.
Results
Analysis revealed that high eye contact and
forward trunk posture enhanced perceived ther-
apist empathy, therapeutic alliance, and treat-
ment credibility when compared with condi-
tions of low eye contact and upright trunk pos-
ture (see Table 1). Further analysis indicated
that for perceptions of alliance, the positive
impact of trunk posture depended on whether
the therapist had high eye contact, Eye Contact
Posture F(1, 143) 7.44, p .007. With
high eye contact, perceived therapeutic alliance
was greater with forward trunk posture (M
7.7) than when the therapist sat upright (M
7.2), F(1, 143) 18.89, p .001; however,
with low eye contact, perceived alliance was
comparable in the forward (M 6.1) and up-
right (M 6.1) positions, F(1, 143) 0.01,
p .9.
Table 1
Mean Scores for Responsive Behavior (High Eye Contact or Forward Trunk Posture) and Unresponsive
Behavior (Low Eye Contact or Upright Trunk Posture)
Measure Responsive Unresponsive F(1, 143)
Eye contact
Empathy 7.4 6.3 102.57

Alliance 7.5 6.1 108.48

Credibility 6.3 5.2 57.39

Trunk posture
Empathy 6.9 6.7 5.09

Alliance 6.9 6.6 8.63

Credibility 5.9 5.6 4.11

Note. N 144. Each measure assessed on a 10-point scale.

p .05.
161 NONVERBAL BEHAVIOR AND PERCEPTIONS
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Two of the therapists in the study reported a
constructivist orientation and two therapists re-
ported a cognitivebehavioral perspective. Anal-
ysis indicated that the effects of posture on per-
ceived empathy depended on the orientation of the
therapists, Posture Therapist Orientation, F(1,
142) 18.46, p .001. For constructivist thera-
pists, a forward leaning posture (M6.9) yielded
higher ratings of empathy compared with an up-
right posture (M 6.4), F(1, 142) 22.36, p
.001. There was a difference in mean judged em-
pathy when cognitivebehavioral therapists
leaned forward; however, the difference when
cognitivebehavioral therapists adopted a forward
leaning posture (M 7.0) compared with an up-
right posture (M 7.1) was not statistically sig-
nicant, F(1, 142) 1.82, p .2.
Analysis also indicated that the effect of posture
on perceived treatment credibility depended on
the orientation of the therapists, Posture Ther-
apist Orientation, F(1, 142) 7.94, p .006. For
constructivist therapists, ratings of treatment cred-
ibility were higher when the therapist adopted a
forward leaning posture (M6.0) compared with
an upright posture (M 5.3), F(1, 142) 11.98,
p .001. For cognitivebehavioral therapists, the
ratings of treatment credibility were slightly lower
when the therapist leaned forward (M5.9) than
when upright (M6.0); however, this difference
was not statistically signicant, F(1, 142) 0.28,
p .6.
The effect of eye contact or posture might vary
depending on whether a therapist is a male or
female. Analyses, however, did not suggest vari-
ation as a function of therapist sex in this study:
The effect of eye contact and posture on ratings of
empathy, therapeutic alliance, and treatment cred-
ibility did not differ reliably between male and
female therapists (interaction ps .08).
Another possibility is that the results could vary
as a function of participant sex. However, analysis
failed to reveal such interactions: As with therapist
sex, the effect of eye contact and posture on rat-
ings of empathy, therapeutic alliance, and treat-
ment credibility did not vary reliably between
male and female participants (interaction ps .1).
Discussion
These results demonstrate the inuence of
nonverbal actions on perceptions of the psycho-
therapy interaction. When therapists engage in
greater eye contact or adopt a forward-leaning
posture, they are viewed as more empathic and
their treatment is judged to be more credible.
Therapists also appear to enhance perceptions
of their relationship with the client when they
lean forward; however, this effect seems to oc-
cur only when therapists also maintain high eye
contact. The results lend empirical support for
the importance of eye contact and posture in
psychotherapy.
Analyses also suggest that the effects of pos-
ture on perceived empathy and treatment cred-
ibility depend on the orientation of the thera-
pists. The two constructivist therapists were
perceived to be more empathetic and their treat-
ment was seen as more credible when they
adopted a forward-leaning posture. A similar
effect was not observed when the two cogni-
tivebehavioral therapists were in a forward-
leaning posture.
One explanation for these effects concerning
therapist orientation is that an engaging and
potentially empathetic behavior like leaning
forward complements the techniques used in
constructivist therapy (e.g., Spooner & Lyddon,
2007) and therefore more strongly inuences
perceptions of constructivist therapists and their
treatment. The fact that this effect for trunk
posture was not observed for the cognitive
behavioral therapists may also be due to a dif-
ference in training. During the creation of the
therapy videos, it was noted that the two cog-
nitivebehavioral therapists did not appear as
comfortable executing the forward lean, possi-
bly because the exercise was newer to them than
to the constructivist therapists. However, there
were only two therapists of each orientation and
they differed in other qualities, so the observed
interaction effect involving therapist orientation
may have very well been a result of other indi-
vidual differences. Given the limited number of
therapists, it would be risky to draw any rm
conclusions about differences arising from ther-
apist orientation.
Given that nonverbal behaviors such as eye
contact and body lean are present in virtually all
forms of psychotherapy, the current observa-
tions could have relevance across therapeutic
orientations. Future research on the relationship
of these and other nonverbal behaviors to treat-
ment outcome could therefore be of importance
to a broad spectrum of psychotherapists, espe-
cially those aiming to integrate and use identi-
ed strengths across orientations.
162 DOWELL AND BERMAN
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Psychotherapy researchers have become in-
creasingly aware of the possibility that the im-
pact of specic therapist behaviors during psy-
chotherapy sessions may be contingent on their
appropriate timing or response to client behav-
iors (e.g., Stiles, Honos-Webb, & Surko, 1998).
However, concerns about timing are less of an
issue in the present study because the two be-
haviors of eye contact and trunk lean were not
used selectively within the brief therapy ses-
sions. Instead, therapists were instructed either
to exhibit or not exhibit each behavior through-
out a session and checks of the videotaped ses-
sions conrmed therapist compliance. Although
our design does not permit an assessment of
timing issues, this question of responsiveness
would be an interesting avenue for future inves-
tigations of these and other therapist nonverbal
behaviors.
Because the results of this study are based on
observer perceptions, they may not reect the
perceptions of actual psychotherapy clients. It
would be helpful for future research to assess
whether the therapist nonverbal behaviors in
this study generate the same perceptions with
therapy clients as found with observers viewing
therapy interactions. On the other hand, the
study did involve experienced therapists, en-
hancing the realism of the expressed nonverbal
behaviors and also increasing the likelihood that
the interaction between the pseudoclients and
therapists mirrored that which would be found
in psychotherapy sessions.
Our research was conducted with a university
population; therefore, the ndings might not
generalize to other groups. For example, differ-
ences have been noted in how nonverbal behav-
iors are interpreted or used depending on the
cultural and diagnostic context (e.g., Annen et
al., 2012; Kim et al., 2003). Additional investi-
gation would be needed to establish whether the
patterns observed in this research extend to
those in other cultures or ethnic groups or to
clients of varying diagnoses.
It has been a common belief that the accuracy
of judgments improves with greater exposure to
the behaviors being observed. For this reason,
some may view the procedure of showing par-
ticipants only brief, 5-min segments of therapy
sessions as a limitation to the study. However,
there is considerable research on the accuracy of
judgments based on limited exposure to nonver-
bal behaviors. Several studies have shown that
meaningful outcomes can be predicted from
very short exposure to nonverbal behavior and
that participant observations over longer peri-
ods of time do not necessarily yield greater
predictive accuracy (e.g., Ambady & Rosenthal,
1992).
The current study did not examine the effects
of therapist nonverbal behaviors on therapy out-
come. The questions of how and to what degree
therapist eye contact and trunk posture affect
therapy outcome have yet to be answered. How-
ever, the results demonstrate that nonverbal be-
haviors inuence perceptions of empathy, ther-
apeutic alliance, and treatment credibility, fac-
tors that are thought to be related to outcome. If
future research conrms that these nonverbal
actions have a similarly positive effect on treat-
ment outcome, it would suggest both the impor-
tance of nonverbal behaviors in the training of
psychotherapists and the benets of therapists
using specic nonverbal behaviors when they
conduct psychotherapy.
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Received April 9, 2012
Revision received August 28, 2012
Accepted September 20, 2012
Call for Brief Reports: Null Results and Failures to Replicate
Journal of Psychotherapy Integration will start publishing a new recurring brief reports
section titled, Surprise, Surprise: Interesting Null Results and Failures to Replicate.
In an era when ndings from psychological science are called into question, it is
especially important to publish carefully constructed studies that yield surprising null
results and/or failures at replicating known effects.
The following 2012 article published in JPI is a good example of a paper that would be
appropriate for this section:
DeGeorge, J., & Constantino, M. (2012). Perceptions of analogue therapist em-
pathy as a function of salient experience. Journal of Psychotherapy Integration,
22, 5259.
Submitted manuscripts should not exceed 2500 words, including references. Manuscript
should be submitted electronically through the journals submission portal under the
Instructions to Authors section at www.apa.org/pubs/journals/int. The deadline for paper
submission will be November 1, 2013.
Please note in your cover letter that you are submitting for this brief reports section. We
look forward to your submissions!
165 NONVERBAL BEHAVIOR AND PERCEPTIONS
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