A new study, published in Psychotherapy, explores the role of therapist empathy in predicting psychotherapy outcomes. The results of this meta-analysis, conducted by Robert Elliott and a team of researchers, suggests that therapist empathy leads to moderately better results in psychotherapy.
“Empathy is an important element of any therapeutic relationship, and worth the investment of time and effort required to do it well and consistently,” Elliott and his coauthors write.
Empathy as a therapist skill was a prominent feature of clinical training during the 60s and 70s after Carl Rogers’s popularization of the term in the 40s and 50s. Following these years, emphasis on empathy in clinical practice declined alongside the rise of a behavioral focus. However, there has been a recent resurrection of attention on empathy in scientific literature, research, and practice. This is marked by an explosion of research on empathy’s function as an essential variable in psychotherapy.
Despite the recent attention, there remains no singular agreed upon definition for empathy. Perhaps it is because of the mounting attention on empathy extending across disciplines that have made it difficult to reach consensus on the definition. Neuroscience, for example, has recently taken part in examining the biological mechanisms of empathy. For some, this representation has legitimized the term’s salience, the authors note.
Elliott and co-authors compiled the “essential features” across contemporary definitions of empathy as follows:
“(1) Empathy is interpersonal and unidirectional, provided by one person to another person. (2) Empathy is conceptualized primarily as an ability or capacity, and occasionally as an action. (3) Empathy involves a range of related mental abilities/actions, including (a) Primarily: Understanding the other person’s feelings, perspectives, experiences, or motivations, (b) But also: Awareness of, appreciation of, or sensitivity to, the other person,(c) Achieved via: Active entry into the other’s experience, described variously in terms of vicariousness, imagination, sharing, or identification.”
This framing of empathy has received criticisms, however, including that it is too broad, mysterious, and in ways, misleading. To aid in their understanding of empathy, Elliott and team draw from the neuroscientific literature. Through these studies, they reflect on three subprocesses of empathy, describing it as: (1) a generally automatic and intuitive emotional stimulation that mirrors another’s bodily experience, (2) “a more deliberate, conceptual, perspective-taking process,” and (3) an emotion regulation process during which the empathizer reappraises and soothes their personal, vicarious emotional reaction that allows them to mobilize their compassion and extend help to the other.
Further, they explore definitions of empathy that have been popular in clinical practice. They note that these definitions tend to be more perceptually oriented, featuring descriptions of empathy occurring alongside higher-order thought processes rather than felt, bodily experiences. For example, they cite Carl Rogers’s (1980) definition of empathy:
“‘The therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. [It is] this ability to see completely through the client’s eyes, to adopt his frame of reference…’. . . ‘It means entering the private perceptual world of the other…being sensitive, moment by moment, to the changing felt meanings which flow in this other person…It means sensing meanings of which he or she is scarcely aware…”
In other practice contexts, the definition of empathy varies further. Descriptions feature themes of establishing a certain kind of rapport that is supportive, understanding, and attuned to the client’s experiences. Further complicating matters is that empathy can be difficult to capture distinctly from other therapeutic components such as “congruence” or “positive regard.”
In this study, Elliott and colleagues conducted a meta-analysis to determine whether therapist empathy predicts success in psychotherapy. While previous meta-analyses have been undertaken to examine whether or not therapist empathy predicts better outcomes, this study was completed as an updated review to capture research within the past five or six years.
Given the diverse definitions of empathy, research instruments used to measure empathy within psychotherapy have been varied and inconsistent. In this meta-analysis, empathy was examined through measures focused on the client, therapist, and observer perceptions of empathy in therapy. Rather than focusing on the presence of empathic therapist responses in sessions, Elliott and team searched for measures that “assessed the quality” of therapists’ empathy. One example is the Barrett-Lennard Relationship Inventory.
In total, 82 studies were analyzed in this meta-analysis. This included just over 6,000 clients who were in therapy for an average of 25 sessions. “For each study, we coded therapy format, theoretical orientation, therapist experience, treatment setting, number of sessions, type of problems, the source of outcome measure, when the outcome was measured, type of outcome measured, the source of empathy measure, and unit of measure,” the authors write.
They found that empathy contributes to moderately better psychotherapy outcomes. More specifically, empathy as defined by client, therapist, and observer perceptions that the therapist is understanding, is a reasonably reliable predictor of successful therapy, accounting for about 9% of the variance in psychotherapy outcomes.
Client measures predicted outcome the most, as compared to therapist and observer measures. Additionally, the influence of empathy on outcome was strongest when therapists were working with clients in the “severe/chronic incarcerated populations” as well as clients whose problems were conceptualized as mixed/unspecified and depressed/anxious. This suggests that client factors shape therapist empathy and its association with therapy outcome. Elliott and team describe their findings further:
“As we have shown, empathy is a robust medium-sized predictor of client outcome in psychotherapy that holds across theoretical orientations, treatment formats, and client problems.”
Their findings also indicated that clients contribute to empathy as well. In other words, who clients are and the kinds of problems they experience influences therapists’ empathy. The authors write, “Empathy may be at least as much a client variable as it is a therapist variable. . . It is probably more accurate to say that empathy is interactionally constructed . . .”
The authors discuss diversity implications and the importance of empathy around sociopolitical positionings and contextual experiences related to social discrimination. They write, “Researchers such as Gillispie, Williams, and Gillispie (2005) have suggested that clients from diverse groups may have a greater need for therapists to be understanding, nonjudgmental, and emotionally supportive during treatment to ensure their participation.”
They conclude with a list of clinical recommendations related to their findings on empathy, including the following points:
- Empathy involves the psychotherapist continuing to understand their clients and demonstrate that understanding. This goes beyond attunement to clients’ words and session content. Rather, therapists must seek to understand clients’ experiences and the nuanced, sometimes unspoken, communication regarding their goals and tasks in therapy.
- Client perspectives, seen to be the best predictor of their therapy outcomes, ought to be regularly assessed and their perspectives of empathy privileged.
- “Empathy is shown as much in how well the therapist receives, listens, respects, and attends to the client as in what the therapist does or says.”
- “There is no evidence that therapists accurately predicting clients’ views of their problems or experiences or self-perceptions is effective. Therapists should neither assume that they are mind readers nor that the client’s experience will match their experience of the client. Empathy is best offered with humility and held lightly, ready to be corrected.”
- “Empathy is not only something that is ‘provided’ by the therapist as if it were a medication, but is a co-created experience between a therapist trying to understand the client and a client trying to communicate with the therapist and be understood.”
- “Empathy entails individualizing responses to particular patients. We found significant heterogeneity in the empathy–outcome association, pointing to the value of personalization and clinical judgment.”
- “Finally, because research has shown empathy to be highly correlated with the other relational conditions, therapists are advised to offer empathy in the context of positive regard and genuineness. Empathy will probably not prove effective unless it is grounded in authentic caring for the client.”
Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399-410. http://dx.doi.org/10.1037/pst0000175
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.