Development of the Therapist Empathy Scale.

Across psychotherapeutic approaches, therapist empathy has been identified as an important nonspecific factor in treatment (Elliott, Bohart, Watson, & Greenberg, 2011; Luborsky, Singer, & Luborsky, 1975) and found to exert medium-sized but variable effects on client outcomes (Bohart, Elliott, Greenberg, & Watson, 2002; Elliott et al., 2011). Definitions of therapist empathy have varied (Bohart & Greenberg, 1997), though they generally have emphasized the therapist’s ability to understand the client’s experience and communicate this understanding to the client (Rogers, 1957; Truax & Carkhuff, 1967). The expression of therapist empathy within sessions is considered a complex process (Bohart et al., 2002; Greenberg & Rushanski-Rosenberg, 2002) comprised of several components: affective (relating and responding to the client’s emotions with similar emotions), cognitive (the intellectual understanding of client experiences; Duan & Hill, 1996; Gladstein, 1983) and attitudinal as demonstrated by warmth and acceptance (Greenberg & Rushanski-Rosenberg, 2002). Other components include the ability to set aside one’s own views to enter the client’s world without judgment or prejudice (Rogers, 1975), and attunement to momentary changes in the client’s presentation, meaning, or concerns (Thwaites & Bennett-Levy, 2007; Watson, 2002; Watson & Prosser, 2002). A review of behavioral correlates of therapist empathy suggests that therapists may demonstrate empathy in session in several ways, including: 1) communicating with an interested, concerned, expressive tone of voice; 2) demonstrating a level of emotional intensity similar to the client’s; and 3) reflecting clients’ statements, nuances in meaning, or unsaid but implied meanings back to them (Watson, 2002). While often considered an interactional process between therapist and client (Barrett-Lennard, 1981), therapist empathy seems to vary more between therapists than to fluctuate within therapists across the clients they treat (Truax et al., 1966). Therefore, most discussions of therapist empathy have focused on therapists’ behaviors and experiences rather than their clients’ reactions to the therapists per se. Therapist empathy assessment methods include therapist self-report ratings (Barrett-Lennard, 1962; King & Holosko, 2011), client ratings (Barrett-Lennard, 1962; Mercer, Maxwell, Heaney, & Watt, 2004; Persons & Burns, 1985), written analogue tasks (Miller, Hedrick, & Orlofsky, 1991), and observer ratings (Elliott et al., 1982; Truax & Carkhuff, 1967; Watson, 1999). Therapist self-reports have been shown to be unreliable, with therapists over-rating their empathy as compared to client report or objective observer ratings (Barrett-Lennard, 1962; Kurtz & Grummon, 1972). Further, the relationship between therapist self-rated empathy and client outcomes appears to be weak (Bohart et al., 2002) or absent (Barrett-Lennard, 1981; Gurman, 1977). In client reports of therapist empathy, clients label therapist behaviors such as self-disclosure and nurturance as empathic (Bachelor, 1988; Watson & Prosser, 2002), reflecting therapist behaviors that may co-occur with therapist empathy but are not necessarily components of it. Written analogue assessments of therapist empathy, such as the Helpful Responses Questionnaire (Miller et al., 1991), may not correlate strongly with direct measures of empathic reflections in client sessions (Miller & Mount, 2001) and are considered a less-preferred alternative to direct observational assessment (Miller et al., 1991). Some observer therapist empathy rating scales exist, such as the Response Empathy Rating Scale (Elliott et al., 1982) and the Accurate Empathy Scale (Truax & Carkhuff, 1967). These scales offer the advantage of providing objective and reliable information useful for psychotherapy process-outcomes research or supervisory feedback (Elliot et al., 2011). However, Watson and Prosser (2002) note limitations of these measures: they reflect only some components of therapist empathy (e.g., Truax & Carkhuff, 1967), include assessment of client responses rather than focusing solely on therapist behavior (e.g., Elliott et al., 1982), or assess nonverbal behaviors that limit their application to videotaped or directly observed therapy sessions (e.g., Watson, 1999). Independent treatment integrity rating scales, such as the Cognitive Therapy Adherence and Competence Scale (Barber, Liese, & Abrams, 2003) or the Motivational Interviewing Treatment Integrity Scale (Moyers, Martin, Manuel, Hendrickson, & Miller, 2005), often include a single item providing a global rating of therapist empathy. Single rating therapist empathy scales may not fully capture all the components of empathy (i.e., cognitive, affective, attitudinal, attunement) and are not likely to be used to examine therapist empathy across different therapy protocols in that these scales have been tied to a particular therapy approach. Watson (1999) identified several observable therapist behaviors indicative of empathy and developed an observer-rated Measure of Expressed Empathy scale that included overlapping components of therapist empathy across its nine items: therapist’s concern for the client, expressivity of voice, capturing the intensity of client feelings, warmth, attunement to the client’s inner world, communicating an understanding of the client’s meanings or cognitive framework, communicating understanding of the client’s feelings and inner experiences, responsiveness to the client, and looking concerned in facial expression or body posture. These items were construed as collectively capturing the higher-order category of therapist empathy in that they conceptually overlapped with one another (Elliott et al., 2011). Intra-class correlation coefficients calculated on a sample of 16 rated client sessions indicated fair to excellent inter-rater reliability (.51 – .85; Cicchetti, 1994). A total scale score showed a significant correlation between observer-rated therapist empathy and client ratings of therapist empathy (n = 15, r = 0.66, p < .01; Watson, 1999). Despite its promise as an observer rating scale assessing multiple components of therapist empathy, the Measure of Expressed Empathy scale is limited by its initial testing on a small sample of client sessions, absence of factor analysis to support its purported single factor, and applicability to videotaped client sessions only. In this report we present the development of an observer-rated adaptation of Watson’s (1999) Measure of Expressed Empathy, called the Therapist Empathy Scale (TES), to assess the observable and overlapping cognitive, affective, attitudinal, and attunement aspects of therapist empathy in audiotaped, rather than videotaped, psychotherapy sessions. Like the Measure of Expressed Empathy scale, the TES was designed to be used across different psychotherapy protocols or approaches, akin to broad based treatment integrity rating systems such as the Yale Adherence and Competence Scale used to capture the proficiency in which therapists deliver a variety of psychotherapeutic approaches (Carroll et al., 2000). Data to evaluate the TES are taken from a study on training therapists in motivational interviewing (MI), a person-centered, empirically supported psychotherapy designed to help enhance motivation for change (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Miller & Rollnick, 2012; Smedslund et al., 2011). Therapists provided audiotaped sessions with substance-using clients in which the therapist used MI (Martino et al., 2010). All sessions were independently rated for therapist MI adherence and competence using the Independent Tape Rater Scale (ITRS), a psychometrically established measure of MI integrity that captures both the fundamental person-centered or relational aspects of MI and more advanced strategic or technical aspects of MI used to directly elicit clients’ motives for change (Martino, Ball, Nich, Frankforter, & Carroll, 2008). Notably, the fundamental MI strategies (e.g., reflective listening skills) are presumably closely linked to the capacity of therapists to express empathy within MI sessions (Miller & Rose, 2009). We present reliability, confirmatory factor analysis, and criterion validity data for the TES. We predicted that the TES items would be reliably rated and converge to form a single factor reflecting a higher-order category of therapist empathy based on all the individually assessed components. We hypothesized that TES and the ITRS-derived fundamental and advanced MI strategy scores would be positively associated, with larger magnitudes of association occurring between therapist empathy and fundamental MI strategy scores than advanced MI strategy scores. In addition, we expected TES scores to show modest positive correlations to scores derived from an alternative established measure of therapist empathy, the Helpful Response Questionnaire (Miller et al., 1991). Finally, we expected therapist empathy scores to be negatively associated with an index of MI inconsistency derived from the ITRS. Because data for the TES study were taken from a clinician training study, client outcome indicators and measures of working alliance were not available.