Therapist Empathy Research Articles

Therapists’ emotional responses and their relation to patients’ experience of attunement and responsiveness

Objective Therapists’ emotional responses play a significant role in the therapeutic relationship and in the therapy process. The current study examined the associations between therapists’ emotional responses before and after therapy sessions, and patients’ experience of them as attuned and responsive. Method Forty patient-therapist dyads participated in 16 weekly sessions of Supportive Expressive Psychotherapy. Therapists’ emotions were assessed on the Feeling Word Checklist-58. We examined one positive feeling (Parental) and one negative feeling (Inadequate) Following each session, patients and therapists rated responsiveness on the Patient’s Experience of Attunement and Responsiveness. Results Feeling Parental before sessions was associated with patients’ post-session ratings of therapist empathy, but not with session helpfulness or sensed achievement. Therapists’ feelings of inadequacy before sessions were negatively associated with patients’ ratings of helpfulness and achievement, but not with empathy. Therapists’ Parental feelings after the session were positively associated with patients’ ratings and their own ratings on all 3 PEAR subscales. Feeling Inadequate after the session was negatively associated with patients’ ratings of helpfulness, achievement and empathy. Therapists’ ratings were only negatively associated only with helpfulness. Conclusion The study demonstrates that therapists’ emotional reactions play a role in their patients’ experience of their responsiveness.

Testing the efficacy of narrator empathy, self-disclosure, gender, and use of brief motivational interviewing techniques in a brief internet-based intervention for alcohol use.

Nonspecific relational factors, such as therapist empathy, play an important role in therapy effectiveness. Building on this literature, some researchers have attempted to incorporate relational factors into electronic brief interventions (e-BIs) by using interactive narrators to guide participants through the intervention. However, few studies have examined which characteristics of these interactive narrators increase intervention acceptability and efficacy. The present study sought to systematically manipulate animated narrator characteristics in an e-BI and to examine their effects on respondents' alcohol use and subjective reactions. Participants (N = 348) were randomly assigned to 1-16 possible combinations of four narrator-level characteristics in a 2 × 2 × 2 × 2 factorial trial evaluating narrator empathy, self-disclosure, gender, and the use of brief motivational interviewing (BMI) techniques. We measured main and interaction effects of these characteristics on the primary outcome of typical drinks per week at 1-month follow-up. Secondary outcomes included maximum drinks, alcohol consequences, and subjective reactions to the intervention, with additional secondary analyses evaluating moderation by participant gender. Participants showed reductions in all alcohol outcomes. These reductions were stronger for participants exposed to either narrator disclosure or BMI techniques (vs. neither). Participants in the high empathy condition rated the intervention as more supportive, while those exposed to BMI techniques reported feeling more criticized by the intervention. Specific narrator-level characteristics, such as narrator self-disclosure and empathy, may improve the efficacy or acceptability of e-BIs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Presession mood induction in therapists: Effects on therapist empathy.

Previous studies show that therapist mood is associated with psychotherapy processes, but the observational nature of these studies does not allow for causal inference. It is also unclear if other therapist characteristics, such as therapist trait empathy, moderate the relation between therapist mood and process variables. Thirty-four therapists and volunteer client dyads participated in three weekly counseling sessions. Before each session, therapists were induced to experience one of three moods, elation, depression, or neutral, in a counterbalanced order, using a combination of music and the Velten method. After each session, clients rated therapist empathy and session quality, therapists rated session quality, and observers rated therapist empathy using videotapes. Electrocardiogram was collected from therapists and clients during the session to assess heart rate synchrony as an indicator of therapist empathy. Therapist trait empathy moderated the effect of mood induction on observer-rated therapist empathy, such that when induced to experience elation, therapists with high trait empathy were observed to be more empathic, whereas therapists with low trait empathy were observed to be less empathic. Therapists of different trait empathy levels did not differ on observer-rated empathy when induced to experience depression or neutral mood. No significant effect of mood induction was found for client-rated empathy, client- and therapist-rated session quality, or heart rate synchrony. The experimental design offers preliminary evidence that therapist presession mood may influence the psychotherapy process. The findings are explained in light of empathy amplification and empathy attenuation hypotheses in relation to positive emotion. Practice and research implications are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A curvilinear association between therapists' use of discourse particles and therapist empathy in psychotherapy.

This study investigates the relationships between therapists' use of discourse particles and therapist empathy. Discourse particles, commonly found in non-English languages, are verbal elements that constitute metacommunication by encoding speakers' emotions and attitudes, which are typically expressed by nonverbal behaviors (e.g., intonation, tone, facial expression, nodding). We hypothesize an inverted U-shaped curvilinear relationship between therapists' use of discourse particles and therapist empathy, given the notion that an optimal level of therapists' emotion in psychotherapy can facilitate clients' inner experiencing and self-expression. Four psychotherapy sessions each from 39 therapist-client dyads were analyzed. After each session, therapist empathy was rated by trained observers using the Therapist Empathy Scale (TES) and by clients using the Barrett-Lennard Relationship Inventory (BLRI). Multilevel modeling shows that both the person-level negative quadratic term and positive linear term for therapists' usage of discourse particles are significant in predicting mean TES with large effect sizes. The same predictors do not yield significant results in predicting mean BLRI but they trend in similar directions of associations with medium effect sizes. Our results suggest the optimal usage of discourse particles by therapists is around 20.3% (out of all utterances). The nonsignificant results in BLRI may be attributed to the relatively small sample size of our data and the noncommunication orientation of the client-rated measure. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Opening the Black Box of Family-Based Treatments: An Artificial Intelligence Framework to Examine Therapeutic Alliance and Therapist Empathy.

The evidence-based treatment (EBT) movement has primarily focused on core intervention content or treatment fidelity and has largely ignored practitioner skills to manage interpersonal process issues that emerge during treatment, especially with difficult-to-treat adolescents (delinquent, substance-using, medical non-adherence) and those of color. A chief complaint of "real world" practitioners about manualized treatments is the lack of correspondence between following a manual and managing microsocial interpersonal processes (e.g. negative affect) that arise in treating "real world clients." Although family-based EBTs share core similarities (e.g. focus on family interactions, emphasis on practitioner engagement, family involvement), most of these treatments do not have an evidence base regarding common implementation and treatment process problems that practitioners experience in delivering particular models, especially in mid-treatment when demands on families to change their behavior is greatest in treatment - a lack that characterizes the field as a whole. Failure to effectively address common interpersonal processes with difficult-to-treat families likely undermines treatment fidelity and sustained use of EBTs, treatment outcome, and contributes to treatment dropout and treatment nonadherence. Recent advancements in wearables, sensing technologies, multivariate time-series analyses, and machine learning allow scientists to make significant advancements in the study of psychotherapy processes by looking "under the skin" of the provider-client interpersonal interactions that define therapeutic alliance, empathy, and empathic accuracy, along with the predictive validity of these therapy processes (therapeutic alliance, therapist empathy) to treatment outcome. Moreover, assessment of these processes can be extended to develop procedures for training providers to manage difficult interpersonal processes while maintaining a physiological profile that is consistent with astute skills in psychotherapeutic processes. This paper argues for opening the "black box" of therapy to advance the science of evidence-based psychotherapy by examining the clinical interior of evidence-based treatments to develop the next generation of audit- and feedback- (i.e., systemic review of professional performance) supervision systems.

The use of questions in psychotherapy: A review of research on immediate outcomes.

This article defines and illustrates therapist questions in individual psychotherapy and then reviews the naturalistic, empirical research on their effectiveness. The research on immediate impacts of questions in psychotherapy has been mixed. The available research indicates that positive impacts, particularly of open questions, include increased client emotional expressiveness and affective exploration. However, negative impacts have also been found, suggesting that questions may be related to negative client perspectives of the therapist's empathy and helpfulness and session smoothness. The article focuses on definitions and clinical examples as well as research findings and limitations. The article concludes with training implications and therapeutic practice recommendations based on the empirical research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Therapist and client perceptions of empathy in simulated teletherapy sessions

ABSTRACT Empathy is thought to be reduced in videoconference (VC) compared to face-to-face (F2F) therapy. To empirically test this possibility, therapist and client ratings of empathy and its correlates were examined in VC and F2F sessions. Forty-eight students in clinical training programs were randomly assigned to the role of ‘therapist’ or ‘client’, forming 24 dyads. Each dyad completed a simulated clinical session in F2F and in VC and reported on empathy and telepresence. Both therapist and client ratings of empathy were significantly lower in VC compared to F2F. Therapist empathy correlated with telepresence, particularly its physical subcomponent, and therapeutic presence, but these associations were not found for clients. The relationship between empathy and telepresence was investigated further in a real-world study. Twelve clients met with clinical psychology trainees over VC and reported on empathy and telepresence. The associations between therapist empathy, total telepresence, and the physical component of telepresence were replicated. Again, client ratings of empathy and telepresence did not correlate. These results provide the first empirical evidence that empathy is reduced in VC teletherapy compared to F2F and highlight the connection between the degree of empathy felt by therapists and their sense of telepresence during teletherapy.

The Development of the Existential Empathy Questionnaire

Therapist empathy toward existential concerns might be a critical component of clinical practice. This study aims to explore the psychometric properties of the Existential Empathy Questionnaire (EEQ), a self-report instrument developed to measure levels of existential empathy among mental health professionals. The EEQ was completed by a sample of 393 therapists recruited in Belgium, along with measures of general empathy, experiential avoidance, and existential avoidance. To assess the test–retest reliability, 353 participants of the same sample completed the EEQ a second time 2 weeks later. Clinical experience and therapeutic theoretical background were assessed to inform professional characteristics. The results support the use of the EEQ as a unidimensional measure of existential empathy. It demonstrates good internal reliability and temporal stability. A principal components analysis indicates three components with small to moderate intercorrelations, labeled as “Communication,” “Avoidance and Overwhelming Feelings,” and “Resonance and Presence.” EEQ total scores show a moderate positive association with general empathy and a moderate negative association with experiential and existential avoidance. Furthermore, the EEQ significantly uniquely predicts experiential and existential avoidance after controlling for general empathy. Years of clinical practice and a humanistic-oriented therapeutic approach correlated moderately with high EEQ scores.

Formality in psychotherapy: How are therapists' and clients' use of discourse particles related to therapist empathy?

Previous studies explored the preferences for therapists' attire and office setting based on initial impressions as a reference for the formality in psychotherapy. This study examines the formality of psychotherapy by investigating therapists' and clients' use of discourse particles, the linguistic marker and quantifier of the formality in speech, in relation to therapist empathy in different stages of psychotherapy. Four psychotherapy sessions (representing early, mid, and late stages) each from 39 therapist-client dyads were analyzed. Trained observers rated therapist empathy in each session using the Therapist Empathy Scale. Results of multilevel modeling show that synchrony in particle usage, hence synchrony in formality, between clients and therapists is not associated with therapist empathy. Therapists' use of particles (i.e., absolute formality of therapists) was also not associated with therapist empathy. In contrast, the relative formality of therapists plays significant roles: therapist empathy is generally observed when therapists are relatively more formal than the clients (i.e., lower relative usage of particles by the therapists when compared to the clients). However, for clients who speak formally with few particles, therapist casualness (i.e., higher relative usage of particles than the clients) at the beginning of therapy may be interpreted as therapist empathy as therapists help these clients ease into the therapeutic relationships. Our results suggest that the examination of therapists' and clients' use of particles across different stages of treatment may illuminate dynamic interactional styles that facilitate or hinder the psychotherapy process.

Therapist emotion and emotional change with clients: Effects on perceived empathy and session quality.

Therapists' emotion and therapist-client emotional congruence are associated with psychotherapy process and outcome. However, their presession emotional states are not consistently accounted for across studies, and the underlying mechanism is unclear. This study introduces the concepts of directional correspondence (DC), where therapists' and clients' emotions move in a similar direction from pre to postsession, and absolute agreement (AA), where therapist and client become closer in emotions from pre to postsession, to examine congruence in emotional change in therapist and client from pre to postsession. In addition, clients' perception of therapist empathy was investigated as a mediator between therapists' emotion/therapist-client emotional congruence and session outcome. Sixty nine clients and 49 therapists participated in this study over the course of therapy (593 sessions in total). They rated their emotions before and after each session, and clients rated therapist empathy and session quality after each session. Multilevel models showed that therapist presession emotions, therapist-client presession emotional similarity, and DC did not predict therapist empathy and session quality. However, AA predicted better therapist empathy, which in turn predicted better session quality. The partial mediation path was also stronger when therapist and client had more dissimilar presession emotions. Thus, clients may rate a session based on their perception of therapist empathy, which may reflect therapist and client moving toward more similar emotions over a session. In addition, the positive effect of therapist and client growing closer in emotions is especially pronounced when they start sessions in different emotional states. Implications of the findings are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Clients in Simulated Teletherapy via Videoconference Compensate for Altered Eye Contact When Evaluating Therapist Empathy.

Eye contact is frequently associated with an increased perception of empathy and telepresence, but the currently used videoconferencing (VC) technologies diminish the possibility of naturally conveying eye contact. This study compared the empathy, telepresence, and eye gaze patterns of clients in simulated VC teletherapy sessions where eye contact was altered or facilitated. Forty-two would-be clients met with one of four therapists in training for one 20-min simulated teletherapy session taking place via VC. The session either altered or facilitated eye contact perception by manipulating the positioning of the webcams and of the clients in their chair. Eye-tracking data focusing on the eyes, face, and general body regions of interest were obtained for 25 clients. The results show that facilitating eye contact in VC did not increase the clients’ perceptions of empathy or telepresence. However, empathy was associated with greater time spent looking at the eyes and faces of the therapists, but only in the sessions facilitating eye contact. We suggest that clients successfully rely on other verbal and nonverbal cues to detect therapist empathy when eye contact is altered in teletherapy sessions.

Attitudes toward treatment among sex offender treatment providers affect burnout and empathy

ABSTRACT Sex offender treatment providers face unique challenges in their work, and the risks for burnout in this population are significant. Decreased therapist empathy is associated with burnout, and empathy is a key factor in successful sex offender treatment. This study explored whether attitudes toward treatment among 92 sex offender therapists were related to levels of burnout and therapist empathy. Higher levels of burnout were associated with lower levels of empathy, and attitudes toward treatment significantly predicted aspects of burnout and empathy. Demographic variables were unrelated to attitudes toward treatment, but treatment providers working in correctional settings more often believed that sex offenders should remain incarcerated. The importance of understanding factors associated with burnout in this population is discussed, and use of the Attitudes Toward Treatment of Sex Offenders (ATTSO) scale is also considered. Practice Impact Statement This study suggests that attitudes about treatment for sex offenders can affect levels of burnout and empathy for those who provide treatment. Because high burnout and low empathy are both associated with negative outcomes for treatment providers and clients, it is important to understand factors that are related to these experiences.

Explaining engagement in outpatient therapy among adults with serious mental health conditions by degree of therapeutic alliance, therapist empathy, and perceived coercion.

Objective: Adults with serious mental health conditions (SMHC) experience higher rates of disengagement from treatment. Factors associated with engagement in treatment in general for this population include therapeutic alliance, provider empathy, and perceived coercion. This cross-sectional exploratory study addressed the question: To what extent do client perceptions of therapeutic alliance, therapist empathy, and perceived coercion explain the degree of engagement in outpatient therapy for adults with SMHC? Method: An anonymous online survey measuring study variables was completed by 131 participants. The relationship between variables was tested using multivariate regression analysis with hierarchical blocks. Results: After separating therapeutic alliance and therapist empathy in the analysis due to multicollinearity and accounting for the influence of control variables, therapeutic alliance (B = .43, p < .01) and therapist empathy (B = .25, p < .01), but not perceived coercion, were associated with the degree of client engagement. Conclusions and Implications for Practice: For adults with SMHC enrolled in outpatient therapy, therapeutic alliance explained the greatest variation in the degree of engagement. Participants appeared to use outpatient therapy as a main strategy for pursuing recovery, and engagement in therapy may be increased if providers utilize strategies to strengthen expressions of empathy and bolster alliance. Additional research is needed to enhance understanding of engagement in therapy for this population and to develop more sensitive measures for evaluating these constructs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Relational Healing in Psychotherapy: Reaching Beyond the Research

ABSTRACT Therapeutic relationships with well-established alliances and favorable signs of therapist empathy and genuineness are strong predictors of successful psychotherapy. However, amassing the declarative knowledge associated with knowing that a constructive therapeutic relationship contributes to successful outcome is insufficient in preparing a clinician with the procedural knowledge leading to him or her knowing how to competently implement this. The present article strives to address this gap by definitionally and descriptively unpacking key aspects of alliance building, and therapist empathy and authenticity/genuineness, for pragmatic learning purposes. It is argued that a humanistic revival in the education and training of beginning psychotherapists is long overdue to enable them to acquire the self-expansion, relational versatility, and ethical sensibility necessary to optimally perform their clinical duties.

A Functional Approach to the Assessment and Treatment of Non-Suicidal Self-Injury in Veterans: A Dialectical Behavior Therapy–Informed Perspective

Given that non-suicidal self-injury (NSSI) is related to increased odds of suicidal ideation and suicide attempts, treating NSSI in veterans is a key treatment priority to help reduce suicide risk and increase quality of life. Treating NSSI can be difficult for clinicians and training in addressing NSSI can enhance therapist empathy and decrease negative attitudes. The current paper describes prevalence of and risk factors for NSSI in veterans and presents a Dialectical Behavior Therapy (DBT)-informed approach for arriving at a functional understanding of NSSI in order to inform assessment and treatment. This DBT-informed approach is demonstrated with two case examples of veteran clients. While in many circumstances treatment of NSSI may be most effective in the context of full model DBT (i.e., individual therapy, group skills training, phone coaching, and therapist consultation team), many aspects of the functional approach discussed herein are not specific to DBT and could therefore be integrated into behavioral analyses and case formulations conducted within non-DBT therapeutic approaches.

How therapists' emotion recognition relates to therapy process and outcome.

Empathy is an essential characteristic for therapists that explained 9% of the variance in treatment outcomes. Many measures of empathy are based on self-report questionnaires. Therefore, they reflect how a person perceives his empathic abilities, which can be biased from his true abilities. The ability to recognize emotions has been found to be related to empathy and serves as a measure for the use of empathic abilities. In this study, we examined therapists' empathic abilities, using a novel task for recognizing emotions, and looked at how they related to the therapy process and outcomes. The study included 33 patient-therapist dyads. Therapist empathy was assessed with an emotion detection task, the JeFEE. Clients filled questionnaires after each session regarding therapy progress and their symptoms. We found that emotion recognition moderated the change in (a) client secure attachment to therapist, (b) client avoidant attachment to therapist, (c) client working alliance, (d) client rate of tense or upset they felt during the session, (e) client lack of emotional clarity of emotions, (f) client non-acceptance of emotional responses, (g) client overall emotion regulation and (h) client main target complaint. Implication for therapy and therapists' selection and training are discussed.

Face-oriented acts of empathy in psychotherapy

Abstract Using Conversation Analytic (CA) methods, the present study attempts to analyze the various functions of face-based therapist empathy, and how they are sequentially realized in different psychotherapeutic settings. Four types of face-based therapeutic functions are discussed; more specifically, it is illustrated how therapist empathy may serve to maintain, enhance, threaten or even save the client’s face. The findings gained could contribute to a better understanding of the face-based therapeutic functions of empathy; also, the study may inspire researchers to further investigate other functions of therapist empathy in psychotherapy.

It's the therapist and the treatment: The structure of common therapeutic relationship factors

Objective: Prior research has established that common therapeutic relationship factors are potent predictors of change in psychotherapy, but such factors are typically studied one at a time and their underlying structure when studied simultaneously is not clear. We assembled empirically validated relationship factors (e.g., therapist empathy; patient expectations; agreement about goals) into a single instrument and subjected it to factor analysis. Method: The instrument was applied to patients (N = 332) undergoing intensive psychotherapy of different types for depressive disorders, anxiety disorders, eating disorders, and childhood trauma in an inpatient specialized mental health setting. In order to examine the psychometric properties of the scale, we used half the sample (N=164) to conduct exploratory factor analysis (EFA) and parallel analysis before we tested the solution using exploratory structural equation modeling (ESEM) on the second half of the sample (N=168). Measurement invariance analysis was conducted to examine the stability of the factor structure. Results: The analysis yielded two factors, which were termed 1. “Confidence in the therapist” and 2. “Confidence in the treatment.” Discussion: When assessed simultaneously, patients differentiate between their evaluation of the therapist and of the treatment. The results indicate that there is substantial overlap among previously established relationship factors. Trial registration: ClinicalTrials.gov identifier: NCT03503981.

ОСОБЛИВОСТІ ЕМПАТІЇ НА РІЗНИХ ЕТАПАХ ПРОФЕСІЙНОГО СТАНОВЛЕННЯ ПРАКТИЧНИХ ПСИХОЛОГІВ СИСТЕМИ ОСВІТИ

Дослідження емпатії практичних психологів та її трансформацій на різних стадіях професійного становлення є важливим для попередження емоційного вигорання фахівців, збереження їхнього психологічного здоров’я. Метою статті стало вивчення особливостей емпатії у практичних психологів системи освіти на різних етапах професіогенезу. Для емпіричного вивчення показників емпатії було використано «Тест на визначення емпатії» Л. Журавльової, для з’ясування особливостей суб’єктивного переживання різних етапів професійного розвитку досліджуваних – методику «Професійний шлях» Г.Пирог. Результати дослідження засвідчили, що для практичних психологів системи освіти найбільш характерними є середній і високий рівні емпатійності. Серед форм емпатії домінують активні емпатійні ставлення, пов’язані з емоційною і дієвою підтримкою людини. Прояви емпатії пов’язані з віком – чим старшим є психолог, тим вища його загальна емпатійність, хоча при цьому він менше переживає з приводу почуттів іншого. Зв’язок емпатії зі стажем виявлено лише в групі «молодих фахівців»: на початку професійної діяльності відбуваються досить інтенсивні зміни в проявах емпатії у напрямку зменшення її загального прояву і збільшення антиемпатії. Це пояснюється особливостями професійного становлення, а саме: змінами в емоційних оцінках професійно значущих подій, їх підсумках, характері труднощів, що призводить до усвідомлення власних проблем і зниження емпатійності. Після періоду професійної адаптації ставлення психологів системи освіти до власної професії починає мати менш емоційний і більш «інструментальний» характер. Вищий рівень емпатійності виявляється у тих досвідчених психологів, які в професійній діяльності орієнтуються на інших людей і мають високу емоційність. Подальші дослідження плануються у напрямі вивчення зв’язку емпатії практичних психологів з локусом контролю, а також розробці програми розвитку оптимальних емпатійних ставлень для попередження емоційного вигорання.

How Personality Disorders Change in Psychotherapy: a Concise Review of Process.

The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective. The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years. For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.