James B. Anderson
1:the imaginative projection of a subjective state into an object so that the object appears to be infused with it.
2:the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner;also: the capacity for this.
The importance of the relationship between therapist and client has long been recognized as a key to successful intervention. In his landmark work in developing his style of psychotherapy, Carl Rogers advocated a humanistic, client-centered approach to therapy. Central to Rogers' approach was the creation of the relationship between therapist and client. According to Rogers (1946):
If the counselor can create a relationship permeated by warmth, understanding, safety from any type of attack, no matter how trivial, and basic acceptance of the person as he is, then the client will drop his natural defensiveness and use the situation (p. 419).
Since Rogers' work, a strong therapeutic alliance has been reliably demonstrated to be associated with positive therapeutic outcome, regardless of type of therapy. Recognizing the importance of such a relationship, many clinicians have made the assumption that empathy is an essential component of effective therapy. Explicitly or implicitly, it seems that many assume that empathy serves as a mediating variable to achieve the coveted alliance so valuable to positive therapeutic outcome.
A prime example of this assumption can be found within Motivational Interviewing (MI). MI is a contemporary therapeutic approach that has been demonstrated to be efficacious when used to help patients make behavioral changes for a variety of health concerns (smoking, weight loss, diabetes, etc.). While certainly not a magic bullet approach (it's not a "panacea,” as founders William Miller and Stephen Rollnick repeatedly remind us), it is very clearly a very important approach to clinical care that has the potential to make primary care interventions more effective. Listed first amongst principles for an MI approach to talking with patients is the expression of empathy from the therapist towards the patient. While it is clear that therapeutic alliance is important to therapeutic outcome generally, and that expression of empathy may be an important path to such an alliance, I argue that it is the former component ("expression”) that is more vital than the latter ("empathy”).
What is vital to what happens in therapy is a result of what happens in therapy—that is, outcome is related to actions, not a hypothetical construct felt inside of the therapist. Certainly the relationship between the patient and the provider is important, as has been repeatedly demonstrated, but that relationship is an interaction of behaviors that have symbiotic influence on one another. When the construct of therapeutic alliance has been evaluated empirically, a number of variables that influence outcome and treatment retention have been identified, ranging from agreement between patient and clinician about treatment tasks, to level of patient arousal (energy and alertness) to the bond between clinician and patient as characterized by expressions of acceptance and confidence.
While one could argue that it is helpful for a therapist to truly have a subjective sense of what life feels like in his or her patient's shoes in order to exude behaviors typically interpreted by patients (or observers) as representative of clinician empathy, it is not necessary. In fact, a clinician might be able to effectively articulate his or her difficulty understanding a patient's motivations or circumstance to help the patient clarify values, recognize possible dissonance between actions and values, and assert and strengthen autonomy to make decisions even if they are not completely understood by another. The bottom line is that while a good working relationship is important (and perhaps vital) to successful treatment, the way that the therapist feels is not essential to creating such a relationship. It is the interplay of behaviors between individuals involved in this complex interaction is important, and ultimately the way that the patient thinks and feels as a result of the interaction is much more important to therapeutic outcome than the feelings of the therapist.
Does the therapeutic alliance (with or without empathy included) predict positive outcomes in therapy? I called my good friend Trent Codd, III, Cognitive Behavior Therapist Extraordinaire, about the empathy issue. He pointed me to studies by DeRubeis and Feeley (1990) and Feeley, DeRubeis, & Gelfand (1999), examining early and late measurement of process variables, including factors specific to CBT as well as therapeutic alliance/facilitative conditions. The findings of these studies showed that "common factors” including alliance did not affect depression early in treatment (CBT factors did), but were, instead, the consequence of change. Since these common factors were traditionally evaluated at a point when a great deal of symptom change had already occurred they could not be considered causal. These results suggest the field needs to go back and redesign its studies, taking temporal factors into account. In the process, researchers could examine the definition of "alliance,” better operationalize "empathy,” and try to unbundle these to identify which elements have greatest impact (or, the MINC, Minimum Intervention Needed for Change) just like we are doing with multi-component evidence based interventions.
Is empathy relevant? It is an empirical question, which is the easy "out” for any academic with a full in-box. Therapists' assumption that empathy is effective or necessary might be driven by a history of real-world observations; the stuff upon which relevant science is based.
Still, when placing this question in the context of a field working to implement and disseminate our science in new and changing paradigms driven by a new group of consumers, I'm having a hard time empathizing with the issue as a whole. What is the place of empathy or even therapeutic alliance in integrated care? What about in mHealth or eHealth interventions, which are gaining popularity and an evidence base? Treatment in these contexts bears little resemblance to the kind of therapy upon which these concepts of empathy and alliance were originally conceived. Perhaps, for the readers engaged here, it's time to exnovate some of the research targets that made sense in days gone by and consider innovating fresh and relevant targets.
James is a second-year UMass Fellow of Clinical Health Psychology in Primary Care. He received his BA from the University of Wisconsin- Eau Claire, research training from the Neuropsychiatric Institute of UCLA, and his PhD in Clinical Psychology at Western Michigan University.
Jodi is an Associate Professor in the Department of Psychology at East Tennessee State University where her primary professional interest is research, training, and workforce development in rural integrated practice.