Evidence-based psychotherapy relationships: Empathy
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This entry is our analysis of a review or synthesis of research findings added to the Effectiveness Bank. The original review was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the review. Below is a commentary from Drug and Alcohol Findings.

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Evidence-based psychotherapy relationships: Empathy.

Elliott R., Bohart A.C., Watson J.C. et al.
Psychotherapy: 2011, 48(1), p. 43–49.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Elliott at robert.elliott@strath.ac.uk. You could also try this alternative source.

This meta-analytic review commissioned by the American Psychological Association finds that the more therapists communicate their understanding of and compassion for clients, the better the outcomes. Recommendations will aid counsellors and therapists and help workforce development staff foster this important attribute.

Summary Updated in 2018. See Effectiveness Bank analysis.

[Though not specific to patients with drug and alcohol problems, many of the studies in the analyses described below will have included such patients, and the principles are likely to be applicable to these disorders among others, not least because substance use problems generally form part of a complex of broader psychosocial problems.]

This review is one of several in a special issue of the journal Psychotherapy devoted to evidence-based, effective therapist-client relationships. It reports on a research synthesis of the links between outcomes of therapy and how empathic the therapist is or seems to themselves, patients or observers. 'Empathy' has been variously measured from each of these perspectives. It can be seen as being expressed in: a compassionate attitude toward the client; an attempt to show that the therapist understands their experience; active, ongoing effort to stay attuned on a moment-to-moment basis with the client's communications and unfolding experience; and a sustained effort to understand how the client's experiences have led them to think and act as they do. The seminal therapist Carl Rogers described it as, "the therapist's sensitive ability and willingness to understand the client's thoughts, feelings and struggles from the client's point of view".

The review incorporated meta-analyses A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. synthesising results from relevant studies to provide estimates of the overall strength of the link between outcomes and empathy, and to be able to probe for influences on the strength of that link. Strength is expressed as effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. By convention, in the behavioural sciences an effect size of the type used in the featured analyses is considered a small effect at 0.10, a medium effect at 0.30, and a large effect at 0.50. using the 'r' metric, which can be squared to calculate how much of the difference in outcomes can be attributed to differences in the therapy dimension being investigated.

The analyses included English-language studies with samples of five or more clients with genuine clinical problems addressed by therapies averaging at least three sessions, and which related therapist empathy to some measure of outcome including symptom change, improvement ratings, client satisfaction, and post-session progress ratings. The resulting 57 studies conducted 224 separate tests of the empathy-outcome association among 3599 clients in 59 different samples.

Main findings

Overall the strength of the link between empathy and therapy outcomes equated to an effect size of 0.31, a statistically significant link representing a moderate relationship which accounts for about 9% of the variance in outcomes, similar to that reported for the relation between alliance and outcomes in adult psychotherapy. In other words, the more the therapist communicates their understanding of and compassion for the client, the better the outcomes.

However, effect size varied across the studies more than would be expected by chance. Possible reasons for this variation were explored. One possible influence which was not statistically significant was the therapist's theoretical orientation, contradicting an earlier suggestion that the link was stronger in cognitive-behavioural therapy. Also unrelated to the strength of the link was the degree to which therapists could accurately predict how clients would rate themselves on various characteristics. The link was strongest when measured from the client's point of view but still moderate and statistically significant when assessed by observers or therapists. Empathy appeared to matter more (ie, the link to outcomes was stronger) when the therapist was relatively inexperienced.

Though these could not be assessed in the meta-analysis, there is also evidence that the cognitive abilities to think in abstract terms and adopt other perspectives are related to empathy. Therapists who are open to conflictual, counter-transferential feelings have also been perceived as more empathic, as have therapists with backgrounds or characteristics similar to those of their clients. Also important is the therapist's 'body language' and way of communicating, including their posture, vocal quality, ability to encourage exploration using emotion words, being nonjudgmental, attentive, open to discussing any topic, and paying attention to details. On the negative side, perceptions of empathy suffered when therapists too often did the talking, gave advice, interrupted, avoided eye contact, or dismissed the client's position while imposing their own.

The client also clearly influences therapist empathy. For example, clients who are more open to and able to communicate their inner experiences will be easier to empathise with. Empathy truly appears to be a mutual process of shared communicative attunement. On the other hand, not all clients respond well to explicit empathic expressions, in particular clients who are highly sensitive, suspicious, poorly motivated, or reactive against authority. However, when therapists are truly empathic, they will be attuned to these clients and adjust how and how much they express empathy.

Practice recommendations

Empathy is a medium-sized, variable predictor of outcome in psychotherapy. The most robust evidence is that clients' perceptions of feeling understood by their therapists relate to outcome. This repeated finding, in dozens of individual studies and in multiple meta-analyses, leads to a series of clinical recommendations.

An empathic stance on the part of the therapist is an essential goal of all psychotherapists, regardless of theoretical orientation, treatment format, and severity of patient psychopathology.

It is important for psychotherapists to make efforts to understand their clients, and to demonstrate this understanding through responses that address the perceived needs of the client. The empathic therapist's primary task is to understand experiences rather than words. Empathic therapists do not parrot clients' words back or reflect only the content of those words; instead, they understand overall goals as well as moment-to-moment experiences.

Therapist responses that accurately respond to and carry forward the meaning in the client's communication are useful. These responses might: convey understanding of client experience; validate the client's perspective; try to bring their experience alive using rich, evocative, concrete, connotative language which often has a probing, tentative quality; or attempt to get at what is implicit in clients' narratives but not yet articulated – guesses grounded in what the client has presented.

Empathic therapists help clients express their experience in words and to become aware of and monitor their emotional responses, so that clients can deepen their experience and reflexively examine their feelings, values, and goals. To this end, therapists attend to what is not said, or what is at the periphery of awareness, as well as that which is said and is focal.

Empathy entails individualising responses to particular patients. For example, fragile clients may find the usual expressions of empathy intrusive, while hostile clients may find empathy too directive, and others may find an empathic focus on feelings alien. Therapists therefore need to know when and when not to respond empathically. When clients do not want therapists to be explicitly empathic, truly empathic therapists will use their perspective-taking skills to provide an optimal therapeutic distance.

There is no evidence that accurately predicting clients' own views of their problems or self-perceptions is effective. Therapists should assume neither that they are mind readers nor that their experience of understanding the client will be matched by the client feeling understood. Empathy should always be offered with humility and held lightly, ready to be corrected.

Finally, because research has shown empathy to be inseparable from the other relational dimensions, therapists should seek to offer empathy in the context of positive regard and genuineness. Empathy will not be effective unless it is grounded in authentic caring for the client. Empathy should be valued as both an 'ingredient' in a healthy therapeutic relationship and a specific, effective response which strengthens the client's sense of self and promotes deeper exploration.

Findings logo commentary This article was in a special issue of the journal Psychotherapy devoted to effective therapist-client relationships. For other Findings entries from this issue see:
Evidence-based psychotherapy relationships: Psychotherapy relationships that work II
Evidence-based psychotherapy relationships: Alliance in individual psychotherapy
Evidence-based psychotherapy relationships: The alliance in child and adolescent psychotherapy
Evidence-based psychotherapy relationships: Alliance in couple and family therapy
Evidence-based psychotherapy relationships: Cohesion in group therapy
Evidence-based psychotherapy relationships: Goal consensus and collaboration
Evidence-based psychotherapy relationships: Positive regard
Evidence-based psychotherapy relationships: Congruence/genuineness
Evidence-based psychotherapy relationships: Collecting client feedback
Evidence-based psychotherapy relationships: Repairing alliance ruptures
Evidence-based psychotherapy relationships: Managing countertransference
Evidence-based psychotherapy relationships: Research conclusions and clinical practices

The special issue which contained the article featured above was the second from the task force. The first was a special issue of the Journal of Clinical Psychology. While the second aimed to identify elements of effective therapist-client relationships ('What works in general'), the first aimed to identify effective ways of adapting or tailoring psychotherapy to the individual patient ('What works in particular'). For Findings entries from this first special issue see this bulletin. Both bodies of work have also been summarised in this freely available document from the US government's registry of evidence-based mental health and substance abuse interventions.

Last revised 27 May 2011. First uploaded

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