ARTICLES
Clinicians’ Cognitive and Affective Biases and the
Practice of Psychotherapy
Joel Yager, M.D., Jerald Kay, M.D., Kimberly Kelsay, M.D.
Objective: Cognitive and affective biases are essentially
connected to heuristic shortcuts in thinking. These biases
ordinarily function outside of conscious awareness and
potentially affect clinical assessment, reasoning, and deci-
sion making in general medicine. However, little consider-
ation has been given to how they may affect clinicians in
the conduct of psychotherapy. This article aims to illus-
trate how such biases may affect assessment, formulation,
and conduct of psychotherapy; describe strategies to mit-
igate these influences; and draw attention to the need for
systematic research in this area.
Methods: Cognitive and affective biases potentially influencing
clinical assessment, reasoning, and decision making in medi-
cine were identified in a selective literature review. The authors
drew from their experiences as psychotherapists and psycho-
therapy supervisors to consider how key biases may influence
psychotherapists’ conduct of psychotherapy sessions.
Results: The authors reached consensus in selecting illus-
trative biases pertinent to psychotherapy. Included biases
That psychotherapists’ judgments regarding their patients
are sometimes illogical and can potentially skew what tran-
spires during psychotherapy is not news. As Macdonald and
Mellor-Clark (1) aptly put it, “Human nature confers a vul-
nerability to biases, blind spots, and self-enhancing illusions,
which frequently distort our capacity to make rational sense
of ourselves and our environment. Freud would hardly be
surprised!” Psychotherapists are not immune to these vul-
nerabilities. Although varieties of countertransference and
other factors related to therapists’ subjective judgments
have been discussed for more than 100 years, a specific
focus on heuristics, cognitive biases, and affective biases
among psychotherapists has been limited. This article invites
attention to these issues, illustrates how such biases may
adversely affect the conduct of psychotherapy, describes
strategies to mitigate these influences, and calls for system-
atic research in this area.
Conceptions of countertransference have expanded over
the years. Early Freudian formulations emphasized
Am J Psychother 74:3, 2021
related to anchoring, ascertainment, availability, base-rate
neglect, commission, confirmation, framing, fundamental
attribution error, omission, overconfidence, premature clo-
sure, sunk costs, and visceral reactions. Vignettes based on
the authors’ combined experiences are provided to illustrate
how these biases could influence the conduct of
psychotherapy.
Conclusions: Cognitive and affective biases are likely to play
important roles in psychotherapy. Clinicians may reduce the
potentially deleterious effects of biases by using a variety of
mitigating strategies, including education about biases,
reflective review, supervision, and feedback. How extensively
these biases appear among psychotherapists and across
types of psychotherapy and how their adverse effects may
be most effectively alleviated to minimize harm deserve sys-
tematic study.
Am J Psychother 2021; 74:119–126;
doi: 10.1176/appi.psychotherapy.20200025
countertransference as representing psychoanalysts’ uncon-
scious reactions to patients, determined by their own life
histories and the contents of their unconscious. These reac-
tions include “personal countertransference,” unconscious
hostile and/or erotic feelings toward patients that interfere
with objectivity and limit therapists’ effectiveness. Later
HIGHLIGHTS
• Cognitive and affective biases, stemming in part from
intuitive, fast-thinking processes, can contribute to
illogical thinking, affect medical decision making, and
adversely affect the conduct of psychotherapy.
• Cognitive and affective bias-related processes are
likely to mediate experiences of countertransference.
• Debiasing strategies applicable in general medical settings
can also be applied to reduce the adverse consequences
of biases in the conduct of psychotherapy.
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CLINICIANS’ COGNITIVE AND AFFECTIVE BIASES AND THE PRACTICE OF PSYCHOTHERAPY
interpretations expanded to include all of a therapist’s reac-
tions to his or her patients (2, 3). Countertransference may
now refer to numerous biases, including those related to
gender (4), cultural ethnocentrism (5, 6), religion (7), social
class, and other broadly held biases, because they affect how
therapists experience patients in psychotherapy (8–11).
Furthermore, the concept of the “intersubjective field,”
based in object-relations and self-psychology psychoanalytic
theories, has highlighted the intimate emotional interper-
sonal dance that continuously occurs between therapist and
patient. The intersubjective field reflects personality elements
and histories brought to therapeutic encounters separately
by therapists and patients that join to create new kinds of
therapeutic relationships (12). This concept acknowledges
that therapists’ subjectivity is requisite and undoubtedly pro-
vides key avenues for understanding patients—but it is
subjective. Overall, discussions of countertransference and
intersubjectivity have focused largely on the contents of
these biases but far less on their structural characteristics,
that is, exactly how they come to pass.
In contrast, the work of Daniel Kahneman and Amos
Tversky and their collaborators and successors focuses on
the structural characteristics of heuristics. These mental
shortcuts heavily influence everyday decision making and
how related cognitive and affective biases come about (13,
14). Heuristics represent cognitive strategies that are auto-
matically and unconsciously used, particularly in decision
making (15). Cognitive biases refer to predispositions to
think in ways that lead to failures in judgment (i.e., errors
that occur when heuristics miss their marks) (16). Affective
biases refer to the various ways that emotions and feelings
affect judgment (16); emotions and motivation can also influ-
ence and provoke cognitive biases (14).
To contrast fast, intuitive thinking (type 1) with slow,
logical deliberative thinking (type 2), a dual-process model of
thinking has been proposed (17–20). Intuitive thinking is
largely driven by heuristics and is subject to numerous sys-
tematic errors. This model considers how everyday decision-
making processes can be warped by fast thinking, which may
lead to such problems as jumping to erroneous conclusions,
lazy and prejudicial thinking, and related cognitive biases.
Croskerry and others (21–26) have demonstrated the impact
of cognitive and affective biases on diagnostic reasoning, clini-
cal decision making, and quality of care in emergency and
general medicine settings. In systematic reviews, Saposnik et al.
(27) and Blumenthal-Barby and Krieger (28) have reported on
cognitive biases linked to diagnostic inaccuracies and subopti-
mal management of clinical problems.
This work in is highly pertinent to the practice of psy-
chotherapy, in which clinicians constantly make moment-to-
moment decisions during initial diagnostic assessments and
ongoing psychotherapy about what to attend to, focus on,
and highlight. Psychotherapists rapidly shift their attention
between what is being discussed and what is being avoided
and constantly readjust perspectives for themselves and
their patients. Consequently, psychotherapists’ intuitions and
120 psychotherapy.psychiatryonline.org
instantaneous decision-making processes are likely to be
influenced by the same biases; studies have shown the qual-
ity of psychotherapists’ intuitions to be highly variable (29,
30). At any moment, why does a psychotherapist attend to
or ignore one specific issue rather than another?
Within this context, this article attempts to extend the
work on how biases can affect medical assessment and deci-
sion making in the practice of psychotherapy. We illustrate
how cognitive and affective biases may adversely affect the
conduct of psychotherapy, describe strategies to mitigate
these influences, and call for systematic research in this
area.
METHODS
We conducted a selective PubMed literature search to inves-
tigate how cognitive and affective biases may affect psycho-
therapy practice, targeting the terms “cognitive bias” and
“psychotherapy” in the title or abstract. The search yielded
12 publications containing these terms. Notably, none of
these articles addressed cognitive biases of therapists (11
concerned cognitive biases of patients, and one described
cognitive-bias-like states in rats).
To illustrate the impact of cognitive and affective biases
on the practice of psychotherapy, we decided to limit our
selection of biases to those reported in the general medical
literature (21–28). Through discussion, we reached consensus
on a list of biases we saw as most pertinent to psychotherapy.
We then drew from our experiences as psychotherapists and
psychotherapy supervisors to create prototypical vignettes.
RESULTS
We initially selected 17 cognitive and affective biases from
the medical literature for consideration. Four of these were
similar enough to be combined, reducing our final set to 13,
as detailed in the case presentations below and in Table 1.
The first case presented below, in which one of the authors
(J.Y.) was involved as a colleague, is based on a prior publi-
cation (31). The other examples are composites based on
clinical elements from our collected experiences rather than
on individual cases. The vignettes demonstrate how each
type of bias can alter the moment-to-moment conduct of
psychotherapy sessions and shape the course of the psycho-
therapy over time. The biases we enumerate below provide
an illustrative, not exhaustive, list.
Availability Bias: Vignette
The availability bias (closely related to “recency bias”) is the
tendency to judge things as more likely if they readily come
to mind. An excellent example of the availability bias has
been provided by Gitlin (31), in describing his reactions to
the suicide of a patient. For months after one of his psycho-
therapy patients committed suicide, Dr. Gitlin became preoc-
cupied with thoughts that many of his patients might be
suicidal. Subsequently, whenever patients remarked about
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TABLE 1. Additional examples of cognitive and affective biases pertinent to the conduct of psychotherapy
Bias type
Anchoring: the tendency to perceptually lock onto initial
salient features in the patient’s presentation within the
diagnostic process and, failing to adjust this initial
impression in the light of later information, becoming
ossified into a certain way of thinking
Ascertainment: the tendency to selectively sample data
on the basis of how the clinician’s thinking is shaped
by prior expectation
Base-rate neglect: the tendency to ignore the true
prevalence of disease, either inflating or
underestimating the occurrence of conditions under
consideration
Commission: the tendency to act rather than wait, see,
and reflect; more likely to occur among overconfident
clinicians
Confirmation: the tendency to look for confirming
evidence to support a hunch or belief, even when
substantial evidence exists to refute it, rather than to
look for disconfirmation
Fundamental attribution error: the tendency to
overemphasize dispositional or personality-based
explanations for behaviors observed in others (judging
the “kind” of persons they are) and under-emphasizing
situational explanations for their behavior; at the same
time, people tend to explain their own behaviors as
resulting from situations rather than from their
personal dispositions
Omission: the tendency to wait and see or to avoid and
neglect difficult issues; more likely seen among self-
doubting clinicians; contrasts with commission bias
Overconfidence: the universal tendency to believe one
knows more than he or she does; reflects a tendency
to act on incomplete information, intuitions, or
hunches; too much faith is placed in opinion instead
of in carefully gathered evidence
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YAGER ET AL.
Example
Early in a multiyear psychotherapy, in a rare moment of brooding
despair, Mr. C. mused about whether life was worth the effort.
Dr. D. fastened on this remark and for years tended to think of
Mr. C. as potentially suicidal, even though nothing in his past or
intercurrent history suggested suicidal concerns.
On the basis of her hunch that childhood trauma played a major role
in Ms. L.’s development and personality formation, Dr. M. devoted
hours to inquiring about possible childhood abuse, neglect, and
mistreatment, even when Ms. L. felt she had offered all possible
details. At the same time, Dr. M. asked very little about other
pertinent life events, interpersonal interactions, and behaviors that
proved to be of great significance in Ms. L.’s history and current
difficulties.
Because the rate of tobacco smoking and intermitted marijuana use
among his psychotherapy patients was so high, Dr. F. often
neglected to include these issues in his diagnostic formulations or
problem lists to be addressed during long-term therapy, whereas
they were undeniably ongoing causes for health concern and
chronically maladaptive coping mechanisms.
Known for being an active psychotherapist, Dr. O. routinely had
difficulty restraining herself from offering numerous suggestions
and giving advice to patients without fully hearing them out.
Although some patients appreciated receiving these suggestions
(many unsolicited), others clearly did not. Several patients asked
whether this was supposed to be how psychotherapy went—they
thought that the idea was for patients to figure things out for
themselves.
Having determined that Mr. Q.’s wife was the major contributor to
their marital discord, Dr. R. kept asking about her role in their
various disputes, underlining what he heard as the wife’s
contributions, and supporting Mr. Q.’s contentions that their
problems were all his wife’s fault. At the same time, Dr. R.
consistently overlooked, disregarded, or minimized the equal or
greater roles Mr. Q. played in provoking and sustaining these
disputes.
In treating Mr. X., a man in his early 30s, for moodiness, depressive
symptoms, and marital difficulties, Dr. W. tended to attribute all of
Mr. X.’s difficulties to an underlying “depressive character,” which
Dr. W. depicted as negativistic and pessimistic even though before
the current episode of depression Mr. X. had been easygoing and
had no history of clinical depression. Dr. W. tended to minimize the
impact of two facts: Mr. X. had come under the thumb of a harsh
manager at work, and shortly after Mr. X. married a few years ago,
his wife developed chronic medical illnesses and had become
increasingly withdrawn, depressed, irritable, and nonfunctioning.
Dr. P. often felt unsure of himself and felt comfortable sinking into
the role of the “silent” therapist who said little. Consequently, he
often failed to follow up on important leads or inquire about
sensitive issues regarding substance use and sexuality. He
rationalized his avoidance by saying that if it were important
enough, the patient would bring the issue up spontaneously. He
seemed unaware that his failure to inquire or follow up often gave
patients the excuse they needed to keep hiding some important
issues from themselves as well as from Dr. P.
Characteristically someone to “go with his hunches” during the
course of his psychotherapies, Dr. N. was known for boldly
declaiming interpretations as facts, some of which showed brilliant
insights and some of which were entirely wrong. Not directly tied
to overconfidence per se, even when his errors were subsequently
pointed out, he would often attempt to rationalize and justify his
mistakes.
continued
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TABLE 1, continued
Bias type
Premature closure: the tendency to stop thinking after
discovering one explanation or certainty; other closely
related biases are the search satisficing bias (the
tendency to stop searching once something at all is
found), the unpacking principle bias (the tendency to
fail to elicit all relevant information in establishing a
differential diagnosis), representativeness restraint bias
(the tendency to look for the commonplace but not
consider the unusual), and vertical line failure bias (the
tendency to maintain narrowly focused, orthodox
styles and to think in silos, failing to ask, “What else
might this be?”)
Visceral: the tendency for affective arousal, both positive
and negative “gut reaction” feelings toward patients, to
influence ongoing interactions; aligns with classic
considerations of countertransference
feeling depressed, Dr. Gitlin would interrogate them about
whether they were having suicidal fantasies, often with little
basis to substantiate his impression. As detailed in his
report, at one point a patient eventually became so exasper-
ated with Dr. Gitlin’s persistent questions about overdo-
sing—which she had never done or even threatened to
do—that she told him, “Look, I can’t promise that I won’t
kill myself, but I promise that if I do it, it won’t be with
your pills. So, leave me alone already!’”
Dr. Gitlin’s visceral reactions, emotional arousal, and
increased vigilance concerning suicide contributed to his
heightened tendency to widely seek, and possibly see, signs
of suicidality in all his patients, more so than was usual
in his previous practice. After his patient’s admonition,
Dr. Gitlin handled this threat of therapeutic rupture by
acknowledging to the patient that he had become overly
sensitive about suicide because of his recent experience. The
patient’s blunt feedback also allowed him to continue to
treat her successfully and helped him become aware of his
bias. Dr. Gitlin also sought additional feedback from a men-
tor and, with his own psychotherapist, engaged in additional
reflection about his reactions. He realized that his heighted
attention to risks of suicide among his patients was associ-
ated with concern about his mentor’s opinion of him and
his own doubts about his professional competence.
Framing Bias: Vignette
Framing bias (closely related to the “context error bias”)
explains that the ways we perceive a problem may be
strongly influenced by the way in which the problem is ini-
tially framed (e.g., on the basis of the patient’s previous diag-
noses). One of the authors (J.K.) began treating a prominent
corporate executive because the executive’s wife, convinced
of his infidelity, demanded that he seek counseling. The
patient was intelligent, confident, and eloquent. From the
beginning of the first visit, he adamantly and repeatedly
maintained his innocence and provided multiple examples
122 psychotherapy.psychiatryonline.org
Example
After learning that Ms. G. had experienced a sexual assault in early
childhood, Dr. H. stopped asking about many other facets of early
development, other untoward life events, and about Ms. G.’s other
problematic interactions with her parents and caregivers. He
assumed that the key to all of Ms. G.’s difficulties were attributable
to this traumatic event. Thereafter, Dr. B. repeatedly tried to focus
Ms. G. on “uncovering” the roots of her many diverse problems as
connected to this event.
Dr. U. found himself drawn to Ms. V. because of her generally sunny
disposition, intermittent childlike sad expressions, and physical
attractiveness. As a result, during their therapy he regularly
overlooked or minimized her accounts of acting-out behavior,
lying, and shoplifting and neglected to encourage her to face these
aspects of her character or to see them as problematic.
of his wife’s instability. Although the psychiatrist empathic-
ally posed multiple questions about behaviors that may
have been construed as unfaithful, the patient convincingly
described that he agreed to these sessions to humor his
wife, who was misguided, if not delusional. After the third
session, the patient stated that, in fact, nothing in his life
supported his wife’s claims, and he was ending treatment.
The clinician tended to agree with the patient, and no fur-
ther visits were scheduled. Two weeks later, the wife called,
desperately requesting to meet with the psychiatrist, who
agreed to see her. Although depressed and anxious about
her failing marriage, she was not seeking treatment but was
planning to move away after finding her husband at their
home in bed with his secretary. The wife explained that she
wanted validation and confirmation from the psychiatrist
that her behavior was not disturbed.
After this meeting, the psychiatrist recognized that he
had been gullible and taken in by the patient. On reflection,
he realized that from the first contact, the patient’s status,
reputation, and convincing portrayal of his wife’s psycholog-
ical instability had biased the psychiatrist’s subsequent
thinking, leading him to assume that the patient was telling
the truth.
Sunk Costs Bias: Vignette
The sunk costs bias is the tendency, after making consider-
able investment, to continue putting effort and resources
into ventures that appear increasingly unlikely to succeed
(i.e., the unwillingness to let go of a failing strategy). For
clinicians, these investments include time and energy. This
bias was originally associated with financial investments.
Dr. A., a psychiatric resident, described a 15-year-old girl
he had been treating for 6 months in weekly psychotherapy
as anxious, rigid, and selfish. After initiating psychotherapy
in one setting, they continued working together after his
transfer to another clinic and supervisor. Dr. A. reported
that his previous supervisor felt that he needed more time
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with this patient to make headway, especially because he
was seeing her only weekly. Dr. A. had spent many sessions
attempting to build an alliance and understand his patient,
exploring her interests, playing board games, and discussing
her immersion in video games. Although Dr. A. felt he knew
a lot about her interests, he could not describe much about
her inner life. Her parents were willing to have her continue
therapy, pleased that their daughter was less resistant to this
therapy than to previous therapeutic attempts. Although the
patient’s anxiety remained high and she still avoided school,
her parents felt the investment of time would start to pay off.
The new supervisor asked to review some video-recorded
sessions and noted that the patient had many features
suggestive of autism. He wondered whether the difficulties
Dr. A. and the previous supervisor had experienced in ques-
tioning the patient’s lack of therapeutic response were partly
related to the sunk costs bias.
DISCUSSION
On the basis, primarily, of the work of Croskerry and his
colleagues in general medicine (21–26), we have illustrated
how cognitive and affective biases related to heuristic men-
tal shortcuts initially studied by Kahneman and Tversky (13,
14) may have an impact on the conduct of psychotherapy.
Personal skews and biases may intrude and shape clinicians’
attentional foci during every session and in turn may
account for significant differences in the moment-to-
moment interactions initiated by psychotherapists. In addi-
tion to the biases noted above, others may be added to this
list as well. For example, a “self-serving” bias may apply to
the conduct of psychotherapy, affecting decision making
related to a range of competing interests, including the
clinician’s intellect, face-saving, longing for intimacy, and
financial considerations (32). Hindsight biases may lead to
“I-told-you-so” moments, in which clinicians selectively
recall prior remarks that seemed to predict an outcome,
conveniently neglecting those that may have communicated
contrary messaging (33, 34).
By distorting judgments, cognitive and affective biases
can impair the development of successful therapist-patient
relationships from the outset of treatment and can contrib-
ute to risks of making patients feel misunderstood and to
ruptures in the therapeutic alliance during treatment. Thera-
pist anxiety may increase tendencies to fall back on fast
thinking and susceptibility to specific biases (e.g., the
anchoring bias may result in distorted imprinting on unim-
portant or distracting issues). Cognitive and affective biases
can contribute to therapist gullibility in cases where thera-
pists might unquestioningly believe patient’s distortions or
lies, for example about marital fidelity or substance misuse.
Biases may distort and preempt how a therapist hears the
patient’s affect and concerns, leading to failure in authentic
attunement with the patient.
Omission bias bears specific mention in relation to psy-
chodynamic psychotherapy. Acts of omission by the
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YAGER ET AL.
therapist may be erroneously justified by misinterpretations
of the classical psychoanalytic psychotherapist’s role, where
the therapist remains silent and passive in order to offer a
blank screen onto which patients project feelings, fantasies,
and wishes. Justifying omissions to foster the emergence of
transference neurosis is a common problem among novice
psychodynamic therapists.
Overconfidence bias may reflect narcissistic blindness or
overcompensation for self-doubt in the psychotherapeutic
role. It may be easier to dazzle patients with “brilliant”
interventions than to struggle with the difficulties of tolerat-
ing ambiguity and engaging in the self-questioning so neces-
sary for effective clinical work.
Premature closure bias (and the closely related “vertical
line failure biases”) have been noted in relation to many
types of psychotherapy. Clinicians affected by this bias may
be close minded, sometimes because of allegiance to narrow
theoretical models, which blind them to other ways of think-
ing. Procrustean approaches, in which observations about
patients are distorted to fit the theory, may result when
therapists lack attunement to the bigger clinical picture. By
avoiding narrow-minded thinking, clinicians who are adap-
tive experts assume broad-based understandings of their
patients’ problems and are open to examining all models, in
contrast to experts who rely primarily on their own familiar,
well-practiced routines (35). Notably, additional clinical expe-
rience alone does not guarantee that clinicians will be more
immune to cognitive biases, such as premature closure (36).
Visceral biases lie at the core of countertransference
reactions in any type of treatment situation. Problems are
more likely to occur when clinicians immediately act on
their visceral reactions rather than reflecting on what these
reactions are signaling. When therapists viscerally respond
to patients by experiencing telltale signs such as boredom,
sleepiness, irritation, erotic feelings, repugnance, anger, over-
helpfulness, strong idealization, or feeling threatened, for
example, these signals can pave the way toward greater
accuracy in treatment by pulling therapists deeper into
patients’ inner worlds. Exploring whether such signals may
also be experienced by others with whom patients interact
outside therapeutic settings can enrich therapists’ under-
standing of their patients. By carefully acknowledging and
selectively sharing their own feelings, therapists’ may help
some patients to better identify and deal with feelings that
the patients have difficulty tolerating.
In some of the clinical examples provided in this article,
therapeutic stalemates or near ruptures occurred when
therapists failed to see or acknowledge their own roles in
the difficulty, at least initially. Almost all such ruptures can
be addressed, but only if clinicians are open to acknowledg-
ing their contributions and are willing to confront them. As
illustrated, other biases result in failures to perform adequate
initial assessments, for example failure to fully inquire about
biological and social factors and to accurately understand
key events precipitating the patient’s application for treat-
ment, all of which may highlight underlying core issues.
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Attempts to align cognitive and affective biases with cus-
tomary views of countertransference are complicated by the
lack of clear and widely accepted definitions for these terms
and by the fact that studies concerning biases and counter-
transference have been developed through different intel-
lectual traditions, virtually in separate silos. Whereas the
broadest definitions of countertransference may subsume cog-
nitive and affective biases, Croskerry et al. (23) have consid-
ered countertransference, emotional biases, and fundamental
attribution errors to be separate sources of emotional influ-
ence on clinical performance. Factors contributing to clinician
biases may include hardwiring (genetics, temperament), regu-
lation by emotions, overlearning (repetitive exposure), implicit
learning, and deliberate but erroneous use of biases that have
become established through previous inferior decision making
(37). Each of these processes is also likely to contribute vul-
nerabilities to broadly defined countertransference.
How might adverse effects of clinicians’ cognitive and
affective biases on the conduct of psychotherapy be allevi-
ated? Because these biases are deeply entrenched, mitigation
is difficult and unlikely to occur easily or to be sustained
with single applications of one-size-fits-all techniques (26).
A systematic review (38) identified 60 mitigation strategies,
the majority of which were shown to be at least partially
successful. These debiasing strategies have used combina-
tions of cognitive, technological, affective, and motivational
approaches. Cognitive approaches have aimed to increase
individuals’ awareness and critical thinking, technological
approaches have used graphs and statistics to inform indi-
viduals about problems concerning base-rate neglect or
framing biases, affective approaches have focused on or
induced feelings associated with biases, and motivational
approaches have attempted to hold individuals accountable
for the results of their biases (38). Overall, in the context of
solving real-world problems, case-based learning appears to
be more effective than simple presentation of abstract rules
(39, 40).
Several techniques developed for general medical settings
may be applicable for psychotherapy. Among the sug-
gested cognitive bias mitigating approaches are debiasing
approaches, such as being more skeptical, affective debias-
ing, metacognition, mindfulness and reflection, slowing
down strategies, rebiasing, personal accountability, educating
intuition, and cultural training (41–43); detailed instruction
and education concerning cognitive biases (44); formal feed-
back (1); consideration of alternatives; increased attention to
certain types of ignored data (Bayesian thinking) (45, 46);
and decreasing reliance on memory (45). These strategies
are consistent with long-standing traditions of psychother-
apy education, personal reflection, and supervision. The
majority of these strategies are aimed at helping clinicians
slow down, reflect, and think deliberately. We recommend
the following techniques.
First, we suggest psychological immunization that is
based on educating psychotherapists about the existence of
these biases early during their training so that they may be
124 psychotherapy.psychiatryonline.org
aware of the dangers when initially forming professional
identities as psychotherapists. All psychotherapy training
programs, regardless of theoretical orientation, can review
these biases and their potential impact at the beginning and
can address them repeatedly throughout training. Learning
to detect and minimize the adverse effects of countertrans-
ference, including biases, is a key element of psychothera-
pists’ professionalization and is essential for establishing
safe, empathic, and nonjudgmental environments. Because
cognitive and affective biases occur more often when thera-
pists’ cognitive resources are stressed or limited, clinicians
should be educated about cognitive resources or load and
should monitor their own sleep, physical health, stress lev-
els, and time pressures as well as their strong emotions,
throughout their careers (23).
Second, psychotherapists can practice several techniques
for metacognitive reflection, reviewing how they conduct
psychotherapy by recollecting, writing, and reflecting on
session-by-session progress notes and by reviewing audio
and video recordings of psychotherapy sessions.
Third, at all career stages, psychotherapists can
benefit from individual or group supervision, where
countertransference-related issues are identified and dis-
cussed. Formal feedback can mitigate the influences of bias
on therapy (1). (As in one of the cases presented above, even
direct informal feedback from patients can be impactful.)
Especially during training, there may be no substitute for
seminars led by seasoned teachers using process notes and
video recordings, in which trainees present ongoing therapy
cases to groups of peers. Interpersonal process recall
offers a specific technique for microscopically reviewing
psychotherapy processes and may be especially helpful for
detecting the intrusion of biases (47). Especially useful are
examinations of complex cases that have warning signs of
potential bias, where the case is not proceeding as expected
or where the therapeutic alliance is slipping. In accord with
the concept of “slow medicine” in internal medicine, which
advocates not rushing into new treatments or paths until
they are substantiated, the overriding purpose is to help
therapists think before they speak or act. To our knowledge,
no formal tools or self-assessment measures have yet been
developed to assist with efforts to identify cognitive biases
in the conduct of psychotherapy, but calls for their develop-
ment in other health settings have appeared in the literature
(38). Such tools could help supervisors more systematically
attend to biases among trainees.
Finally, this preliminary report raises numerous questions
for further study. For example, can we develop formal tools,
including self-assessment measures, to better identify cogni-
tive biases in the conduct of psychotherapy? How do psy-
chotherapists differ in their propensities for various biases
and the frequency with which these occur in their psycho-
therapies? How do different psychotherapy approaches and
techniques vary in their vulnerabilities to psychotherapists’
biases? How do bias differences translate to specific coun-
tertransference vulnerabilities, including those related to
Am J Psychother 74:3, 2021

ethnocentricities and gender biases? What accounts for the
variances among all these characteristics? If we can identify
these biases during training and supervision, how can miti-
gating strategies be used to best alter their adverse impacts?
Additionally, how do all these factors influence the outcome
of psychotherapy?
CONCLUSIONS
In summary, we have called attention to the potential impact
of cognitive and affective biases that accompany heuristic
mental shortcuts on the conduct of psychotherapy. Vignettes
showing pertinent cognitive and affective biases have been
used to illustrate how these biases may affect psychothera-
pists’ perceptions and decision making, both moment to
moment and over time. Although heuristics are clearly valu-
able tools of thought, several practical strategies are avail-
able to help mitigate the negative impact of co-occurring
cognitive and affective biases on psychotherapy practice.
Because these considerations are preliminary, much remains
to be investigated regarding the frequency, variability, modi-
fiability, and ultimate clinical significance of these biases in
the conduct and outcomes of psychotherapy.
AUTHOR AND ARTICLE INFORMATION
Department of Psychiatry, University of Colorado School of Medicine,
Aurora (Yager, Kelsay); Department of Psychiatry, Boonshoft School of
Medicine, Wright State University, Dayton, Ohio (Kay).
Send correspondence to Dr. Yager (joel.yager@cuanschutz.edu).
The authors report no financial relationships with commercial interests.
Received June 19, 2020; revisions received August 3 and October 12,
2020; accepted October 27, 2020; published online January 15, 2021.
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